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09:00am - 10:30am EDT - May 6, 2023 | Room: S103 (McCormick Place)
Yalini Vigneswaran, Moderator; Michael Smith, Moderator; Prashant Kedia, Moderator
Society: DDW
Type: Clinical Symposium
Society: DDW

LIVE STREAM SESSION

Saturday
09:00am - 09:22am EDT - May 6, 2023 | Room: S103 (McCormick Place)
Amber Shada, Presenter
Society: DDW
Type: Clinical Symposium

Society: DDW

LIVE STREAM SESSION


Saturday
09:22am - 09:44am EDT - May 6, 2023 | Room: S103 (McCormick Place)
Kenneth Chang, Presenter
Society: DDW
Type: Clinical Symposium
Society: DDW

LIVE STREAM SESSION

Saturday
09:44am - 10:06am EDT - May 6, 2023 | Room: S103 (McCormick Place)
Mujjahid Abbas, Presenter
Society: DDW
Type: Clinical Symposium
Society: DDW

LIVE STREAM SESSION

Saturday
10:06am - 10:28am EDT - May 6, 2023 | Room: S103 (McCormick Place)
Michael Smith, Presenter
Society: DDW
Type: Clinical Symposium
Society: DDW

LIVE STREAM SESSION

09:00am - 10:30am EDT - May 6, 2023 | Room: W190a (McCormick Place)
Allison Yang, Moderator; Michele Lewis, Moderator; Anna Phillips, Moderator
Society: AGA
Type: Clinical Symposium
Society: AGA


Saturday
09:00am - 09:23am EDT - May 6, 2023 | Room: W190a (McCormick Place)
Dhiraj Yadav, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA


Saturday
09:23am - 09:45am EDT - May 6, 2023 | Room: W190a (McCormick Place)
Temel Tirkes, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA


Saturday
09:45am - 10:08am EDT - May 6, 2023 | Room: W190a (McCormick Place)
Chris Forsmark, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA


Saturday
10:08am - 10:30am EDT - May 6, 2023 | Room: W190a (McCormick Place)
Aatur Singhi, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA


09:00am - 10:30am EDT - May 6, 2023 | Room: W195 (McCormick Place)
Jeremy Louissaint, Moderator; Victor Chedid, Moderator
Society: AGA
Type: Clinical Symposium
Society: AGA

The use of technology has expanded rapidly in clinical care and research in gastroenterology. Telehealth has improved access to care and transformed the ability to monitor patients from the safety of their own homes. Artificial intelligence has improved our predictive models and diagnostic capabilities. Social media is emerging as a tool to reach populations previously unengaged by health care. Despite these promising advances, disparities are increasingly being recognized in the creation, implementation, and use of these technologies. In this session, we will highlight disparities within telehealth and artificial intelligence/machine learning, but also outline evidence-based methods to promote equity within these disciplines. We will also discuss the role of social media in creating diverse communities for practitioners, advocates, and patients, and review how social media has facilitated outreach to vulnerable communities.

Saturday
09:00am - 09:15am EDT - May 6, 2023 | Room: W195 (McCormick Place)
Society: AGA
Type: Clinical Symposium
Society: AGA

The use of technology has expanded rapidly in clinical care and research in gastroenterology. Telehealth has improved access to care and transformed the ability to monitor patients from the safety of their own homes. Artificial intelligence has improved our predictive models and diagnostic capabilities. Social media is emerging as a tool to reach populations previously unengaged by health care. Despite these promising advances, disparities are increasingly being recognized in the creation, implementation, and use of these technologies. In this session, we will highlight disparities within telehealth and artificial intelligence/machine learning, but also outline evidence-based methods to promote equity within these disciplines. We will also discuss the role of social media in creating diverse communities for practitioners, advocates, and patients, and review how social media has facilitated outreach to vulnerable communities.

Saturday
09:15am - 09:30am EDT - May 6, 2023 | Room: W195 (McCormick Place)
Julius Wilder, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA

The use of technology has expanded rapidly in clinical care and research in gastroenterology. Telehealth has improved access to care and transformed the ability to monitor patients from the safety of their own homes. Artificial intelligence has improved our predictive models and diagnostic capabilities. Social media is emerging as a tool to reach populations previously unengaged by health care. Despite these promising advances, disparities are increasingly being recognized in the creation, implementation, and use of these technologies. In this session, we will highlight disparities within telehealth and artificial intelligence/machine learning, but also outline evidence-based methods to promote equity within these disciplines. We will also discuss the role of social media in creating diverse communities for practitioners, advocates, and patients, and review how social media has facilitated outreach to vulnerable communities.

Saturday
09:30am - 09:45am EDT - May 6, 2023 | Room: W195 (McCormick Place)
Patricia Bloom, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA

The use of technology has expanded rapidly in clinical care and research in gastroenterology. Telehealth has improved access to care and transformed the ability to monitor patients from the safety of their own homes. Artificial intelligence has improved our predictive models and diagnostic capabilities. Social media is emerging as a tool to reach populations previously unengaged by health care. Despite these promising advances, disparities are increasingly being recognized in the creation, implementation, and use of these technologies. In this session, we will highlight disparities within telehealth and artificial intelligence/machine learning, but also outline evidence-based methods to promote equity within these disciplines. We will also discuss the role of social media in creating diverse communities for practitioners, advocates, and patients, and review how social media has facilitated outreach to vulnerable communities.

Saturday
09:45am - 10:00am EDT - May 6, 2023 | Room: W195 (McCormick Place)
Sravanthi Parasa, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA

The use of technology has expanded rapidly in clinical care and research in gastroenterology. Telehealth has improved access to care and transformed the ability to monitor patients from the safety of their own homes. Artificial intelligence has improved our predictive models and diagnostic capabilities. Social media is emerging as a tool to reach populations previously unengaged by health care. Despite these promising advances, disparities are increasingly being recognized in the creation, implementation, and use of these technologies. In this session, we will highlight disparities within telehealth and artificial intelligence/machine learning, but also outline evidence-based methods to promote equity within these disciplines. We will also discuss the role of social media in creating diverse communities for practitioners, advocates, and patients, and review how social media has facilitated outreach to vulnerable communities.

Saturday
10:00am - 10:15am EDT - May 6, 2023 | Room: W195 (McCormick Place)
Megan A. Adams, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA

The use of technology has expanded rapidly in clinical care and research in gastroenterology. Telehealth has improved access to care and transformed the ability to monitor patients from the safety of their own homes. Artificial intelligence has improved our predictive models and diagnostic capabilities. Social media is emerging as a tool to reach populations previously unengaged by health care. Despite these promising advances, disparities are increasingly being recognized in the creation, implementation, and use of these technologies. In this session, we will highlight disparities within telehealth and artificial intelligence/machine learning, but also outline evidence-based methods to promote equity within these disciplines. We will also discuss the role of social media in creating diverse communities for practitioners, advocates, and patients, and review how social media has facilitated outreach to vulnerable communities.

Saturday
10:15am - 10:30am EDT - May 6, 2023 | Room: W195 (McCormick Place)
Russell Rosenblatt, Presenter; Julius Wilder, Presenter; Patricia Bloom, Presenter; Sravanthi Parasa, Presenter; Megan A. Adams, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA

The use of technology has expanded rapidly in clinical care and research in gastroenterology. Telehealth has improved access to care and transformed the ability to monitor patients from the safety of their own homes. Artificial intelligence has improved our predictive models and diagnostic capabilities. Social media is emerging as a tool to reach populations previously unengaged by health care. Despite these promising advances, disparities are increasingly being recognized in the creation, implementation, and use of these technologies. In this session, we will highlight disparities within telehealth and artificial intelligence/machine learning, but also outline evidence-based methods to promote equity within these disciplines. We will also discuss the role of social media in creating diverse communities for practitioners, advocates, and patients, and review how social media has facilitated outreach to vulnerable communities.

09:00am - 10:30am EDT - May 6, 2023 | Room: W192 (McCormick Place)
Jenifer Lightdale, Moderator; Russell Merritt, Moderator
Society: AGA
Type: Clinical Symposium
Society: AGA

There have been numerous times in the past few years wherein natural or man-made disasters have impacted the production and supply chain of key constituents of both enteral and parenteral nutrition products. These have impacted individuals on total parenteral nutrition (TPN) and on tube feeds or children/infants that are exclusively fed formula or suffer from metabolic or allergic disorders that necessitate them being on certain medical foods/specialty formula. As a community gastroenterolgists have been asked to step up in these situations to advocate for and construct disaster management plans. Through this session we would like to raise awareness for these general issues and provide state of the art guidance for these specific issues pertinent to daily clinical practice. LIVE STREAM SESSION

Saturday
09:00am - 09:20am EDT - May 6, 2023 | Room: W192 (McCormick Place)
Amanda Fifi, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA

There have been numerous times in the past few years wherein natural or man-made disasters have impacted the production and supply chain of key constituents of both enteral and parenteral nutrition products. These have impacted individuals on total parenteral nutrition (TPN) and on tube feeds or children/infants that are exclusively fed formula or suffer from metabolic or allergic disorders that necessitate them being on certain medical foods/specialty formula. As a community gastroenterolgists have been asked to step up in these situations to advocate for and construct disaster management plans. Through this session we would like to raise awareness for these general issues and provide state of the art guidance for these specific issues pertinent to daily clinical practice. LIVE STREAM SESSION

Saturday
09:20am - 09:40am EDT - May 6, 2023 | Room: W192 (McCormick Place)
Russell Merritt, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA

There have been numerous times in the past few years wherein natural or man-made disasters have impacted the production and supply chain of key constituents of both enteral and parenteral nutrition products. These have impacted individuals on total parenteral nutrition (TPN) and on tube feeds or children/infants that are exclusively fed formula or suffer from metabolic or allergic disorders that necessitate them being on certain medical foods/specialty formula. As a community gastroenterolgists have been asked to step up in these situations to advocate for and construct disaster management plans. Through this session we would like to raise awareness for these general issues and provide state of the art guidance for these specific issues pertinent to daily clinical practice. LIVE STREAM SESSION

Saturday
09:40am - 10:00am EDT - May 6, 2023 | Room: W192 (McCormick Place)
Timothy Sentongo, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA

There have been numerous times in the past few years wherein natural or man-made disasters have impacted the production and supply chain of key constituents of both enteral and parenteral nutrition products. These have impacted individuals on total parenteral nutrition (TPN) and on tube feeds or children/infants that are exclusively fed formula or suffer from metabolic or allergic disorders that necessitate them being on certain medical foods/specialty formula. As a community gastroenterolgists have been asked to step up in these situations to advocate for and construct disaster management plans. Through this session we would like to raise awareness for these general issues and provide state of the art guidance for these specific issues pertinent to daily clinical practice. LIVE STREAM SESSION

Saturday
10:00am - 10:20am EDT - May 6, 2023 | Room: W192 (McCormick Place)
Jenifer Lightdale, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA

There have been numerous times in the past few years wherein natural or man-made disasters have impacted the production and supply chain of key constituents of both enteral and parenteral nutrition products. These have impacted individuals on total parenteral nutrition (TPN) and on tube feeds or children/infants that are exclusively fed formula or suffer from metabolic or allergic disorders that necessitate them being on certain medical foods/specialty formula. As a community gastroenterolgists have been asked to step up in these situations to advocate for and construct disaster management plans. Through this session we would like to raise awareness for these general issues and provide state of the art guidance for these specific issues pertinent to daily clinical practice. LIVE STREAM SESSION

Saturday
10:20am - 10:30am EDT - May 6, 2023 | Room: W192 (McCormick Place)
Amanda Fifi, Presenter; Russell Merritt, Presenter; Timothy Sentongo, Presenter; Jenifer Lightdale, Presenter
Society: AGA
Type: Clinical Symposium
Society: AGA

There have been numerous times in the past few years wherein natural or man-made disasters have impacted the production and supply chain of key constituents of both enteral and parenteral nutrition products. These have impacted individuals on total parenteral nutrition (TPN) and on tube feeds or children/infants that are exclusively fed formula or suffer from metabolic or allergic disorders that necessitate them being on certain medical foods/specialty formula. As a community gastroenterolgists have been asked to step up in these situations to advocate for and construct disaster management plans. Through this session we would like to raise awareness for these general issues and provide state of the art guidance for these specific issues pertinent to daily clinical practice. LIVE STREAM SESSION

09:00am - 10:30am EDT - May 6, 2023 | Room: S106 (McCormick Place)
Eileen Carpenter, Moderator; Ajay Goel, Moderator
Society: AGA
Type: Research Symposium
Society: AGA

The epigenome is the heritable portion of the genome that is mediated by chemical modification of DNA (methylation) or nuclear proteins (histones, transcription factors) without changing the DNA sequence. This session will focus on what defines the epigenome, technologies that allow us to track the epigenome and how novel cancer therapies are developed that target regulators of the epigenome.

Saturday
09:00am - 09:25am EDT - May 6, 2023 | Room: S106 (McCormick Place)
Christopher Pin, Presenter
Society: AGA
Type: Research Symposium
Society: AGA

The epigenome is the heritable portion of the genome that is mediated by chemical modification of DNA (methylation) or nuclear proteins (histones, transcription factors) without changing the DNA sequence. This session will focus on what defines the epigenome, technologies that allow us to track the epigenome and how novel cancer therapies are developed that target regulators of the epigenome.

Saturday
09:25am - 09:50am EDT - May 6, 2023 | Room: S106 (McCormick Place)
Stephen Meltzer, Presenter
Society: AGA
Type: Research Symposium
Society: AGA

The epigenome is the heritable portion of the genome that is mediated by chemical modification of DNA (methylation) or nuclear proteins (histones, transcription factors) without changing the DNA sequence. This session will focus on what defines the epigenome, technologies that allow us to track the epigenome and how novel cancer therapies are developed that target regulators of the epigenome.

Saturday
09:50am - 10:15am EDT - May 6, 2023 | Room: S106 (McCormick Place)
Ramesh Shivdasani, Presenter
Society: AGA
Type: Research Symposium
Society: AGA

The epigenome is the heritable portion of the genome that is mediated by chemical modification of DNA (methylation) or nuclear proteins (histones, transcription factors) without changing the DNA sequence. This session will focus on what defines the epigenome, technologies that allow us to track the epigenome and how novel cancer therapies are developed that target regulators of the epigenome.

Saturday
10:15am - 10:30am EDT - May 6, 2023 | Room: S106 (McCormick Place)
Christopher Pin, Presenter; Stephen Meltzer, Presenter; Ramesh Shivdasani, Presenter
Society: AGA
Type: Research Symposium
Society: AGA

The epigenome is the heritable portion of the genome that is mediated by chemical modification of DNA (methylation) or nuclear proteins (histones, transcription factors) without changing the DNA sequence. This session will focus on what defines the epigenome, technologies that allow us to track the epigenome and how novel cancer therapies are developed that target regulators of the epigenome.

Society: AGA

The gut microbiome is implicated in a wide range of physiological processes, and holds great, but unrealized, potential for disease treatment and prevention. In this session, rising investigators demonstrate novel biotherapeutic applications of gut microbes, and how the intestinal bacterial community interacts with an arm of the innate immune system. The talks span the topics of bioengineered probiotics, anti-tumor activities of gut microbes, and introduce the complement system in the gut as an effector of antimicrobial defense.

Saturday
09:00am - 09:30am EDT - May 6, 2023 | Room: S102 (McCormick Place)
Meng Wu, Presenter
Society: AGA
Type: Research Symposium
Society: AGA

The gut microbiome is implicated in a wide range of physiological processes, and holds great, but unrealized, potential for disease treatment and prevention. In this session, rising investigators demonstrate novel biotherapeutic applications of gut microbes, and how the intestinal bacterial community interacts with an arm of the innate immune system. The talks span the topics of bioengineered probiotics, anti-tumor activities of gut microbes, and introduce the complement system in the gut as an effector of antimicrobial defense.

Saturday
09:30am - 10:00am EDT - May 6, 2023 | Room: S102 (McCormick Place)
Nicholas Arpaia, Presenter
Society: AGA
Type: Research Symposium
Society: AGA

The gut microbiome is implicated in a wide range of physiological processes, and holds great, but unrealized, potential for disease treatment and prevention. In this session, rising investigators demonstrate novel biotherapeutic applications of gut microbes, and how the intestinal bacterial community interacts with an arm of the innate immune system. The talks span the topics of bioengineered probiotics, anti-tumor activities of gut microbes, and introduce the complement system in the gut as an effector of antimicrobial defense.

Saturday
10:00am - 10:30am EDT - May 6, 2023 | Room: S102 (McCormick Place)
Society: AGA
Type: Research Symposium
Society: AGA

The gut microbiome is implicated in a wide range of physiological processes, and holds great, but unrealized, potential for disease treatment and prevention. In this session, rising investigators demonstrate novel biotherapeutic applications of gut microbes, and how the intestinal bacterial community interacts with an arm of the innate immune system. The talks span the topics of bioengineered probiotics, anti-tumor activities of gut microbes, and introduce the complement system in the gut as an effector of antimicrobial defense.

Society: AGA

Gastritis is frequently encountered by gastroenterologists in their evaluation of patients with foregut-related symptoms. There is an unmet need for GI clinicians to become familiar with the many types of gastritis given the several etiologies present, and the implications for treatment, prognosis, and surveillance. Gastric metaplasia, although uncommon in US populations, presents a quandary for practicing physicians given the general unfamiliarity with its classification, management and prognosis. Several novel endoscopic techniques have been proposed to improve the diagnosis of gastric preneoplastic lesions and help personalize and guide the most appropriate surveillance strategy. The purpose of this session is thus to familiarize clinicians with how to approach and manage the patient with gastritis and/or gastric atrophy/metaplasia with the aim of obtaining a definitive diagnosis, staging and grading the lesion, identifying the likely etiologic factor, and initiating appropriate treatment and surveillance.

Saturday
09:00am - 09:18am EDT - May 6, 2023 | Room: S104 (McCormick Place)
Robert Genta, Presenter
Society: AGA
Type: Translational Symposium
Society: AGA

Gastritis is frequently encountered by gastroenterologists in their evaluation of patients with foregut-related symptoms. There is an unmet need for GI clinicians to become familiar with the many types of gastritis given the several etiologies present, and the implications for treatment, prognosis, and surveillance. Gastric metaplasia, although uncommon in US populations, presents a quandary for practicing physicians given the general unfamiliarity with its classification, management and prognosis. Several novel endoscopic techniques have been proposed to improve the diagnosis of gastric preneoplastic lesions and help personalize and guide the most appropriate surveillance strategy. The purpose of this session is thus to familiarize clinicians with how to approach and manage the patient with gastritis and/or gastric atrophy/metaplasia with the aim of obtaining a definitive diagnosis, staging and grading the lesion, identifying the likely etiologic factor, and initiating appropriate treatment and surveillance.

Saturday
09:18am - 09:36am EDT - May 6, 2023 | Room: S104 (McCormick Place)
Edith Lahner, Presenter
Society: AGA
Type: Translational Symposium
Society: AGA

Gastritis is frequently encountered by gastroenterologists in their evaluation of patients with foregut-related symptoms. There is an unmet need for GI clinicians to become familiar with the many types of gastritis given the several etiologies present, and the implications for treatment, prognosis, and surveillance. Gastric metaplasia, although uncommon in US populations, presents a quandary for practicing physicians given the general unfamiliarity with its classification, management and prognosis. Several novel endoscopic techniques have been proposed to improve the diagnosis of gastric preneoplastic lesions and help personalize and guide the most appropriate surveillance strategy. The purpose of this session is thus to familiarize clinicians with how to approach and manage the patient with gastritis and/or gastric atrophy/metaplasia with the aim of obtaining a definitive diagnosis, staging and grading the lesion, identifying the likely etiologic factor, and initiating appropriate treatment and surveillance.

Saturday
09:36am - 09:54am EDT - May 6, 2023 | Room: S104 (McCormick Place)
Society: AGA
Type: Translational Symposium
Society: AGA

Gastritis is frequently encountered by gastroenterologists in their evaluation of patients with foregut-related symptoms. There is an unmet need for GI clinicians to become familiar with the many types of gastritis given the several etiologies present, and the implications for treatment, prognosis, and surveillance. Gastric metaplasia, although uncommon in US populations, presents a quandary for practicing physicians given the general unfamiliarity with its classification, management and prognosis. Several novel endoscopic techniques have been proposed to improve the diagnosis of gastric preneoplastic lesions and help personalize and guide the most appropriate surveillance strategy. The purpose of this session is thus to familiarize clinicians with how to approach and manage the patient with gastritis and/or gastric atrophy/metaplasia with the aim of obtaining a definitive diagnosis, staging and grading the lesion, identifying the likely etiologic factor, and initiating appropriate treatment and surveillance.

Saturday
09:54am - 10:12am EDT - May 6, 2023 | Room: S104 (McCormick Place)
Society: AGA
Type: Translational Symposium
Society: AGA

Gastritis is frequently encountered by gastroenterologists in their evaluation of patients with foregut-related symptoms. There is an unmet need for GI clinicians to become familiar with the many types of gastritis given the several etiologies present, and the implications for treatment, prognosis, and surveillance. Gastric metaplasia, although uncommon in US populations, presents a quandary for practicing physicians given the general unfamiliarity with its classification, management and prognosis. Several novel endoscopic techniques have been proposed to improve the diagnosis of gastric preneoplastic lesions and help personalize and guide the most appropriate surveillance strategy. The purpose of this session is thus to familiarize clinicians with how to approach and manage the patient with gastritis and/or gastric atrophy/metaplasia with the aim of obtaining a definitive diagnosis, staging and grading the lesion, identifying the likely etiologic factor, and initiating appropriate treatment and surveillance.

Saturday
10:12am - 10:27am EDT - May 6, 2023 | Room: S104 (McCormick Place)
Robert Genta, Presenter; Francesco Di Mario, Presenter; Mario Dinis-Ribeiro, Presenter; Edith Lahner, Presenter
Society: AGA
Type: Translational Symposium
Society: AGA

Gastritis is frequently encountered by gastroenterologists in their evaluation of patients with foregut-related symptoms. There is an unmet need for GI clinicians to become familiar with the many types of gastritis given the several etiologies present, and the implications for treatment, prognosis, and surveillance. Gastric metaplasia, although uncommon in US populations, presents a quandary for practicing physicians given the general unfamiliarity with its classification, management and prognosis. Several novel endoscopic techniques have been proposed to improve the diagnosis of gastric preneoplastic lesions and help personalize and guide the most appropriate surveillance strategy. The purpose of this session is thus to familiarize clinicians with how to approach and manage the patient with gastritis and/or gastric atrophy/metaplasia with the aim of obtaining a definitive diagnosis, staging and grading the lesion, identifying the likely etiologic factor, and initiating appropriate treatment and surveillance.

09:00am - 10:30am EDT - May 6, 2023 | Room: S501 (McCormick Place)
Jasmine Sinha, Moderator; Navin Paul, Moderator
Society: ASGE
Type: Clinical Symposium
Society: ASGE

VIDEO SESSION

Saturday
09:00am - 09:02am EDT - May 6, 2023 | Room: S501 (McCormick Place)
Society: ASGE
Type: Clinical Symposium
Society: ASGE

VIDEO SESSION

Saturday
09:02am - 09:22am EDT - May 6, 2023 | Room: S501 (McCormick Place)
Shayan Irani, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

VIDEO SESSION

Saturday
09:22am - 09:42am EDT - May 6, 2023 | Room: S501 (McCormick Place)
Jennifer Phan, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

VIDEO SESSION

Saturday
09:42am - 10:02am EDT - May 6, 2023 | Room: S501 (McCormick Place)
Amy Tyberg, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

VIDEO SESSION

Saturday
10:02am - 10:22am EDT - May 6, 2023 | Room: S501 (McCormick Place)
Society: ASGE
Type: Clinical Symposium
Society: ASGE

VIDEO SESSION

Saturday
10:22am - 10:30am EDT - May 6, 2023 | Room: S501 (McCormick Place)
Society: ASGE
Type: Clinical Symposium
Society: ASGE

VIDEO SESSION

09:00am - 10:30am EDT - May 6, 2023 | Room: S405 (McCormick Place)
Dennis Jensen, Moderator; Katarina Greer, Moderator
Society: ASGE
Type: Clinical Symposium
Society: ASGE

Video Session

Saturday
09:00am - 09:02am EDT - May 6, 2023 | Room: S405 (McCormick Place)
Dennis Jensen, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

Video Session

Saturday
09:02am - 09:14am EDT - May 6, 2023 | Room: S405 (McCormick Place)
Neil Gupta, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

Video Session

Saturday
09:14am - 09:26am EDT - May 6, 2023 | Room: S405 (McCormick Place)
John Saltzman, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

Video Session

Saturday
09:26am - 09:38am EDT - May 6, 2023 | Room: S405 (McCormick Place)
Richard C.K. Wong, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

Video Session

Saturday
09:38am - 09:50am EDT - May 6, 2023 | Room: S405 (McCormick Place)
Riad Salem, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

Video Session

Saturday
09:50am - 09:53am EDT - May 6, 2023 | Room: S405 (McCormick Place)
Society: ASGE
Type: Clinical Symposium
Society: ASGE

Video Session

Saturday
09:53am - 10:23am EDT - May 6, 2023 | Room: S405 (McCormick Place)
Dennis Jensen, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

Video Session

Saturday
10:23am - 10:30am EDT - May 6, 2023 | Room: S405 (McCormick Place)
Society: ASGE
Type: Clinical Symposium
Society: ASGE

Video Session

09:00am - 10:30am EDT - May 6, 2023 | Room: S404 (McCormick Place)
Cynthia Yoshida, Moderator; Joseph Vicari, Moderator
Society: ASGE
Type: Clinical Symposium
Society: ASGE

LIVE STREAM SESSION

Saturday
09:00am - 09:02am EDT - May 6, 2023 | Room: S404 (McCormick Place)
Joseph Vicari, Presenter; Cynthia Yoshida, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

LIVE STREAM SESSION

Saturday
09:02am - 09:17am EDT - May 6, 2023 | Room: S404 (McCormick Place)
Neena Abraham, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

LIVE STREAM SESSION

Saturday
09:17am - 09:32am EDT - May 6, 2023 | Room: S404 (McCormick Place)
Pradeep Bhandari, Presenter; Katie Siggens, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

LIVE STREAM SESSION

Saturday
09:32am - 09:47am EDT - May 6, 2023 | Room: S404 (McCormick Place)
Raju Gottumukkala, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

LIVE STREAM SESSION

Saturday
09:47am - 10:02am EDT - May 6, 2023 | Room: S404 (McCormick Place)
Mark Benson, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

LIVE STREAM SESSION

Saturday
10:02am - 10:17am EDT - May 6, 2023 | Room: S404 (McCormick Place)
Swati Patel, Presenter
Society: ASGE
Type: Clinical Symposium
Society: ASGE

LIVE STREAM SESSION

Saturday
10:17am - 10:27am EDT - May 6, 2023 | Room: S404 (McCormick Place)
Society: ASGE
Type: Clinical Symposium
Society: ASGE

LIVE STREAM SESSION

09:00am - 10:30am EDT - May 6, 2023 | Room: S403 (McCormick Place)
Harmeet Malhi, Moderator; Huiping Zhou, Moderator
Society: AASLD
Type: Topic Forum
Society: AASLD


Saturday
09:00am - 09:15am EDT - May 6, 2023 | Room: S403 (McCormick Place)
Rebecca Wells, Presenter
Society: AASLD
Type: Topic Forum
Society: AASLD


Saturday
Society: AASLD

Background: Chronic cholestatic liver diseases, such as primary sclerosing cholangitis (PSC), often lead to end-stage liver disease requiring liver transplantation. PSC also significantly increases the risk of cholangiocarcinoma (CCA). There is currently no effective therapeutic agent for PSC due to a limited understanding of its pathogenesis. Exosomes carry a variety of bioactive molecules, including miRNAs, lipids and proteins. The dysregulation of miRNAs is closely related to various pathological aspects of PSC. In this study, we aimed to investigate the expression profiles and function of exosomal miRNAs under cholestatic conditions.
Methods: One-year-old Mdr2-/- mice (FVB background) and age-/gender- matched wild-type (WT) mice were used in this study. The serum exosomes were isolated using qEV isolation system (from IZON). Total RNA was isolated from the serum exosomes and liver tissues using Trizol. Total RNA transcriptome was determined by RNAseq. The miRNA profiles in the exosomes and livers were analyzed using the NanoString nCounter® miRNA Expression panel. TargetScan and mirnet2.0 were used to identify the potential target genes. Protein-protein interaction (PPI) was constructed based on the STRING database. Hub genes under cholestatic conditions were visualized by Cytoscape software. The human CCA patient data were downloaded from the Cancer Genome Atlas (TCGA) database.
Results: Bioinformatic analysis identified 74 differentially expressed miRNAs (DE-miRs) and 137 DE-miRs in the male and female Mdr2-/- mice compared to corresponding WT controls, respectively. The identified DE-miRs were used to predict the target genes. GO and KEGG analysis further showed that these DE-miRs were linked to multiple signaling pathways related to cholestatic liver injury. We also identified 431 up-, and 1106 down- DE genes (DEGs) in the Mdr2-/- mice compared to WT mice. From the PPI network analysis of the DEGs, the top 100 hug genes were determined. We identified 11 upregulated DE-miRs in Mdr2-/- mice, which overlapped with the predicted miRs based on the the top 100 hug genes. Interestingly, among the overlapping DE-miRs, two miRs, miR-16 and let-7e, were also upregulated in the serum exosomes of Mdr2-/- mice. Among the 100 hug genes, we identified nine downregulated genes that were potential targets of miR-16 and let-7e. Further analysis of TCGA CCA data showed upregulation of miR-16 and let-7e, and 7 out of the 9 identified targeted genes were also significantly downregulated in CCA compared to healthy controls.
Conclusion: This study identified potential DE-miRs in the liver and serum exosomes which may contribute to cholestatic liver injury. This study supports the possible use of exosomal miRs as diagnostic and prognostic markers and therapeutic targets for cholestatic liver diseases.
<b>Fig 1. Liver DE-miRs and DEGs identification in Mdr2<sup>-/-</sup> mice compared to corresponding WT controls, target prediction and analysis of these DE-miRs and DEGs, and the overlapping miRNAs in cholestatic liver injury.</b><br /> (A)<b> </b>Liver DE-miRs expression profiles between male Mdr2<sup>-/-</sup> and WT controls. (B) Liver DE-miRs expression profiles between female Mdr2<sup>-/- </sup>and WT controls. (C)<b> </b>Liver DEGs expression profiles between Mdr2<sup>-/-</sup> and WT controls. (D) The top 50 hug genes of the PPI network of upregulated DEGs and the top 50 hug genes of the PPI network of downregulated DEGs. (E) Predicted network of miRNAs – 100 identified hug genes of DEGs between Mdr2<sup>-/- </sup>and WT controls. (F) Identification of 11 overlapping upregulated miRNAs in cholestatic liver injury. FC, fold change; miR, micro RNA. DE, differentially expressed, Mdr2<sup>-/-</sup> , multidrug resistance 2 gene knockout; WT, wild type.

Fig 1. Liver DE-miRs and DEGs identification in Mdr2-/- mice compared to corresponding WT controls, target prediction and analysis of these DE-miRs and DEGs, and the overlapping miRNAs in cholestatic liver injury.
(A) Liver DE-miRs expression profiles between male Mdr2-/- and WT controls. (B) Liver DE-miRs expression profiles between female Mdr2-/- and WT controls. (C) Liver DEGs expression profiles between Mdr2-/- and WT controls. (D) The top 50 hug genes of the PPI network of upregulated DEGs and the top 50 hug genes of the PPI network of downregulated DEGs. (E) Predicted network of miRNAs – 100 identified hug genes of DEGs between Mdr2-/- and WT controls. (F) Identification of 11 overlapping upregulated miRNAs in cholestatic liver injury. FC, fold change; miR, micro RNA. DE, differentially expressed, Mdr2-/- , multidrug resistance 2 gene knockout; WT, wild type.

<b>Fig 2. Exosome DE-miRs identification in Mdr2<sup>-/- </sup>mice compared to corresponding WT controls, the overlapping DE-miRs in the liver and serum exosomes, and comparison of the expression levels of these DE-miRs and target genes between normal and CHOL samples in TCGA CCA database.</b><br /> (A) Exosome DE-miRs expression profiles between female Mdr2<sup>-/-</sup> and WT controls. (B) Identification of 2 overlapping upregulated DE-miRs in the serum exosomes which may contribute to cholestatic liver injury. (C) The expression levels of these 2 overlapping upregulated DE-miRs between normal and CHOL samples. (D) Heat map, the expression levels of these target hug genes of 2 overlapping upregulated DE-miRs between normal and CHOL samples.

Fig 2. Exosome DE-miRs identification in Mdr2-/- mice compared to corresponding WT controls, the overlapping DE-miRs in the liver and serum exosomes, and comparison of the expression levels of these DE-miRs and target genes between normal and CHOL samples in TCGA CCA database.
(A) Exosome DE-miRs expression profiles between female Mdr2-/- and WT controls. (B) Identification of 2 overlapping upregulated DE-miRs in the serum exosomes which may contribute to cholestatic liver injury. (C) The expression levels of these 2 overlapping upregulated DE-miRs between normal and CHOL samples. (D) Heat map, the expression levels of these target hug genes of 2 overlapping upregulated DE-miRs between normal and CHOL samples.


Saturday
Society: AASLD

Background: Chronic cholestatic liver diseases, such as primary sclerosing cholangitis (PSC), often lead to end-stage liver disease requiring liver transplantation. PSC also significantly increases the risk of cholangiocarcinoma (CCA). There is currently no effective therapeutic agent for PSC due to a limited understanding of its pathogenesis. Exosomes carry a variety of bioactive molecules, including miRNAs, lipids and proteins. The dysregulation of miRNAs is closely related to various pathological aspects of PSC. In this study, we aimed to investigate the expression profiles and function of exosomal miRNAs under cholestatic conditions.
Methods: One-year-old Mdr2-/- mice (FVB background) and age-/gender- matched wild-type (WT) mice were used in this study. The serum exosomes were isolated using qEV isolation system (from IZON). Total RNA was isolated from the serum exosomes and liver tissues using Trizol. Total RNA transcriptome was determined by RNAseq. The miRNA profiles in the exosomes and livers were analyzed using the NanoString nCounter® miRNA Expression panel. TargetScan and mirnet2.0 were used to identify the potential target genes. Protein-protein interaction (PPI) was constructed based on the STRING database. Hub genes under cholestatic conditions were visualized by Cytoscape software. The human CCA patient data were downloaded from the Cancer Genome Atlas (TCGA) database.
Results: Bioinformatic analysis identified 74 differentially expressed miRNAs (DE-miRs) and 137 DE-miRs in the male and female Mdr2-/- mice compared to corresponding WT controls, respectively. The identified DE-miRs were used to predict the target genes. GO and KEGG analysis further showed that these DE-miRs were linked to multiple signaling pathways related to cholestatic liver injury. We also identified 431 up-, and 1106 down- DE genes (DEGs) in the Mdr2-/- mice compared to WT mice. From the PPI network analysis of the DEGs, the top 100 hug genes were determined. We identified 11 upregulated DE-miRs in Mdr2-/- mice, which overlapped with the predicted miRs based on the the top 100 hug genes. Interestingly, among the overlapping DE-miRs, two miRs, miR-16 and let-7e, were also upregulated in the serum exosomes of Mdr2-/- mice. Among the 100 hug genes, we identified nine downregulated genes that were potential targets of miR-16 and let-7e. Further analysis of TCGA CCA data showed upregulation of miR-16 and let-7e, and 7 out of the 9 identified targeted genes were also significantly downregulated in CCA compared to healthy controls.
Conclusion: This study identified potential DE-miRs in the liver and serum exosomes which may contribute to cholestatic liver injury. This study supports the possible use of exosomal miRs as diagnostic and prognostic markers and therapeutic targets for cholestatic liver diseases.
<b>Fig 1. Liver DE-miRs and DEGs identification in Mdr2<sup>-/-</sup> mice compared to corresponding WT controls, target prediction and analysis of these DE-miRs and DEGs, and the overlapping miRNAs in cholestatic liver injury.</b><br /> (A)<b> </b>Liver DE-miRs expression profiles between male Mdr2<sup>-/-</sup> and WT controls. (B) Liver DE-miRs expression profiles between female Mdr2<sup>-/- </sup>and WT controls. (C)<b> </b>Liver DEGs expression profiles between Mdr2<sup>-/-</sup> and WT controls. (D) The top 50 hug genes of the PPI network of upregulated DEGs and the top 50 hug genes of the PPI network of downregulated DEGs. (E) Predicted network of miRNAs – 100 identified hug genes of DEGs between Mdr2<sup>-/- </sup>and WT controls. (F) Identification of 11 overlapping upregulated miRNAs in cholestatic liver injury. FC, fold change; miR, micro RNA. DE, differentially expressed, Mdr2<sup>-/-</sup> , multidrug resistance 2 gene knockout; WT, wild type.

Fig 1. Liver DE-miRs and DEGs identification in Mdr2-/- mice compared to corresponding WT controls, target prediction and analysis of these DE-miRs and DEGs, and the overlapping miRNAs in cholestatic liver injury.
(A) Liver DE-miRs expression profiles between male Mdr2-/- and WT controls. (B) Liver DE-miRs expression profiles between female Mdr2-/- and WT controls. (C) Liver DEGs expression profiles between Mdr2-/- and WT controls. (D) The top 50 hug genes of the PPI network of upregulated DEGs and the top 50 hug genes of the PPI network of downregulated DEGs. (E) Predicted network of miRNAs – 100 identified hug genes of DEGs between Mdr2-/- and WT controls. (F) Identification of 11 overlapping upregulated miRNAs in cholestatic liver injury. FC, fold change; miR, micro RNA. DE, differentially expressed, Mdr2-/- , multidrug resistance 2 gene knockout; WT, wild type.

<b>Fig 2. Exosome DE-miRs identification in Mdr2<sup>-/- </sup>mice compared to corresponding WT controls, the overlapping DE-miRs in the liver and serum exosomes, and comparison of the expression levels of these DE-miRs and target genes between normal and CHOL samples in TCGA CCA database.</b><br /> (A) Exosome DE-miRs expression profiles between female Mdr2<sup>-/-</sup> and WT controls. (B) Identification of 2 overlapping upregulated DE-miRs in the serum exosomes which may contribute to cholestatic liver injury. (C) The expression levels of these 2 overlapping upregulated DE-miRs between normal and CHOL samples. (D) Heat map, the expression levels of these target hug genes of 2 overlapping upregulated DE-miRs between normal and CHOL samples.

Fig 2. Exosome DE-miRs identification in Mdr2-/- mice compared to corresponding WT controls, the overlapping DE-miRs in the liver and serum exosomes, and comparison of the expression levels of these DE-miRs and target genes between normal and CHOL samples in TCGA CCA database.
(A) Exosome DE-miRs expression profiles between female Mdr2-/- and WT controls. (B) Identification of 2 overlapping upregulated DE-miRs in the serum exosomes which may contribute to cholestatic liver injury. (C) The expression levels of these 2 overlapping upregulated DE-miRs between normal and CHOL samples. (D) Heat map, the expression levels of these target hug genes of 2 overlapping upregulated DE-miRs between normal and CHOL samples.

Background: Following biliary injury/senescence in rodent models of cholestatic liver injury and in patients with PSC, mast cells (MCs) infiltrate the liver and migrate toward cholangiocytes. Proteases such as chymase and tryptase are indicative of MC origination and function, while activated MCs release histamine (HA) that promotes liver inflammation. In human PSC, chymase gene expression is significantly higher than tryptase in these patients. MC chymase induces detrimental effects in cardiac dysfunction, asthma, and lung fibrosis. In vivo, inhibition of chymase reverses acute liver failure and CCl4-induced damage. Similarly, in a PSC mouse model, Mdr2-/-, has increased chymase- and tryptase-positive MC presence at baseline, but after treatment with cromolyn sodium (to block MC activation), these mice display reduced biliary damage/senescence, hepatic fibrosis, and inflammation. Aim: To determine the effects of INVA8001, a specific chymase inhibitor, on PSC phenotypes in Mdr2-/- mice. Methods: 10 wk male Mdr2-/- mice were treated with INVA8001 (20 mg/kg BW/day) for 14 days by daily IP injection. Serum, liver, cholangiocytes, and cholangiocyte supernatants were collected. FVB/NJ (wild-type, WT) and untreated Mdr2-/- mice were utilized for comparison. Liver damage was assessed by H&E staining in liver and total bile acids (TBAs) were measured in serum by EIA. Changes in intrahepatic bile duct mass (i.e., ductular reaction, DR) were determined by semiquantitative CK-19 immunohistochemistry (IHC) and biliary senescence by immunofluorescence (IF) for p16 (costained with CK-19) and qPCR for p16, p21, and p18 in total liver mRNA. Hepatic fibrosis and collagen deposition were evaluated by quantitative Fast Green/Sirius Red staining and qPCR for collagen type 1a and TIMP1 in total liver samples. MC presence was determined by staining for mouse MC protease-1 (marks chymase-positive MCs) and tryptase beta 2 (marks tryptase-positive MCs) and activation by HA serum content and qPCR for mMCP-1 and FCeR1 in total liver. Changes in senescence-associated secretory phenotypes (SASPs) were determined by serum TGF-β1 content using EIA and total liver expression by qPCR. Results: Inhibition with INVA8001 ameliorated DR, hepatic damage, senescence/SASP, and fibrosis along with chymase-positive MC infiltration and activation in Mdr2-/- mice compared to WT and untreated Mdr2-/- mice. Conclusion: Specific inhibition of chymase targets PSC phenotypes ameliorating pathogenesis by decreased biliary senescence and SASP factors. Our studies demonstrate the damaging effects of chymase-positive MCs in PSC and the therapeutic benefit of INVA8001 treatment with potential applicability to other liver diseases wherein MCs promote pathogenesis.

Saturday
Society: AASLD

Background: Chronic cholestatic liver diseases, such as primary sclerosing cholangitis (PSC), often lead to end-stage liver disease requiring liver transplantation. PSC also significantly increases the risk of cholangiocarcinoma (CCA). There is currently no effective therapeutic agent for PSC due to a limited understanding of its pathogenesis. Exosomes carry a variety of bioactive molecules, including miRNAs, lipids and proteins. The dysregulation of miRNAs is closely related to various pathological aspects of PSC. In this study, we aimed to investigate the expression profiles and function of exosomal miRNAs under cholestatic conditions.
Methods: One-year-old Mdr2-/- mice (FVB background) and age-/gender- matched wild-type (WT) mice were used in this study. The serum exosomes were isolated using qEV isolation system (from IZON). Total RNA was isolated from the serum exosomes and liver tissues using Trizol. Total RNA transcriptome was determined by RNAseq. The miRNA profiles in the exosomes and livers were analyzed using the NanoString nCounter® miRNA Expression panel. TargetScan and mirnet2.0 were used to identify the potential target genes. Protein-protein interaction (PPI) was constructed based on the STRING database. Hub genes under cholestatic conditions were visualized by Cytoscape software. The human CCA patient data were downloaded from the Cancer Genome Atlas (TCGA) database.
Results: Bioinformatic analysis identified 74 differentially expressed miRNAs (DE-miRs) and 137 DE-miRs in the male and female Mdr2-/- mice compared to corresponding WT controls, respectively. The identified DE-miRs were used to predict the target genes. GO and KEGG analysis further showed that these DE-miRs were linked to multiple signaling pathways related to cholestatic liver injury. We also identified 431 up-, and 1106 down- DE genes (DEGs) in the Mdr2-/- mice compared to WT mice. From the PPI network analysis of the DEGs, the top 100 hug genes were determined. We identified 11 upregulated DE-miRs in Mdr2-/- mice, which overlapped with the predicted miRs based on the the top 100 hug genes. Interestingly, among the overlapping DE-miRs, two miRs, miR-16 and let-7e, were also upregulated in the serum exosomes of Mdr2-/- mice. Among the 100 hug genes, we identified nine downregulated genes that were potential targets of miR-16 and let-7e. Further analysis of TCGA CCA data showed upregulation of miR-16 and let-7e, and 7 out of the 9 identified targeted genes were also significantly downregulated in CCA compared to healthy controls.
Conclusion: This study identified potential DE-miRs in the liver and serum exosomes which may contribute to cholestatic liver injury. This study supports the possible use of exosomal miRs as diagnostic and prognostic markers and therapeutic targets for cholestatic liver diseases.
<b>Fig 1. Liver DE-miRs and DEGs identification in Mdr2<sup>-/-</sup> mice compared to corresponding WT controls, target prediction and analysis of these DE-miRs and DEGs, and the overlapping miRNAs in cholestatic liver injury.</b><br /> (A)<b> </b>Liver DE-miRs expression profiles between male Mdr2<sup>-/-</sup> and WT controls. (B) Liver DE-miRs expression profiles between female Mdr2<sup>-/- </sup>and WT controls. (C)<b> </b>Liver DEGs expression profiles between Mdr2<sup>-/-</sup> and WT controls. (D) The top 50 hug genes of the PPI network of upregulated DEGs and the top 50 hug genes of the PPI network of downregulated DEGs. (E) Predicted network of miRNAs – 100 identified hug genes of DEGs between Mdr2<sup>-/- </sup>and WT controls. (F) Identification of 11 overlapping upregulated miRNAs in cholestatic liver injury. FC, fold change; miR, micro RNA. DE, differentially expressed, Mdr2<sup>-/-</sup> , multidrug resistance 2 gene knockout; WT, wild type.

Fig 1. Liver DE-miRs and DEGs identification in Mdr2-/- mice compared to corresponding WT controls, target prediction and analysis of these DE-miRs and DEGs, and the overlapping miRNAs in cholestatic liver injury.
(A) Liver DE-miRs expression profiles between male Mdr2-/- and WT controls. (B) Liver DE-miRs expression profiles between female Mdr2-/- and WT controls. (C) Liver DEGs expression profiles between Mdr2-/- and WT controls. (D) The top 50 hug genes of the PPI network of upregulated DEGs and the top 50 hug genes of the PPI network of downregulated DEGs. (E) Predicted network of miRNAs – 100 identified hug genes of DEGs between Mdr2-/- and WT controls. (F) Identification of 11 overlapping upregulated miRNAs in cholestatic liver injury. FC, fold change; miR, micro RNA. DE, differentially expressed, Mdr2-/- , multidrug resistance 2 gene knockout; WT, wild type.

<b>Fig 2. Exosome DE-miRs identification in Mdr2<sup>-/- </sup>mice compared to corresponding WT controls, the overlapping DE-miRs in the liver and serum exosomes, and comparison of the expression levels of these DE-miRs and target genes between normal and CHOL samples in TCGA CCA database.</b><br /> (A) Exosome DE-miRs expression profiles between female Mdr2<sup>-/-</sup> and WT controls. (B) Identification of 2 overlapping upregulated DE-miRs in the serum exosomes which may contribute to cholestatic liver injury. (C) The expression levels of these 2 overlapping upregulated DE-miRs between normal and CHOL samples. (D) Heat map, the expression levels of these target hug genes of 2 overlapping upregulated DE-miRs between normal and CHOL samples.

Fig 2. Exosome DE-miRs identification in Mdr2-/- mice compared to corresponding WT controls, the overlapping DE-miRs in the liver and serum exosomes, and comparison of the expression levels of these DE-miRs and target genes between normal and CHOL samples in TCGA CCA database.
(A) Exosome DE-miRs expression profiles between female Mdr2-/- and WT controls. (B) Identification of 2 overlapping upregulated DE-miRs in the serum exosomes which may contribute to cholestatic liver injury. (C) The expression levels of these 2 overlapping upregulated DE-miRs between normal and CHOL samples. (D) Heat map, the expression levels of these target hug genes of 2 overlapping upregulated DE-miRs between normal and CHOL samples.

Background: Following biliary injury/senescence in rodent models of cholestatic liver injury and in patients with PSC, mast cells (MCs) infiltrate the liver and migrate toward cholangiocytes. Proteases such as chymase and tryptase are indicative of MC origination and function, while activated MCs release histamine (HA) that promotes liver inflammation. In human PSC, chymase gene expression is significantly higher than tryptase in these patients. MC chymase induces detrimental effects in cardiac dysfunction, asthma, and lung fibrosis. In vivo, inhibition of chymase reverses acute liver failure and CCl4-induced damage. Similarly, in a PSC mouse model, Mdr2-/-, has increased chymase- and tryptase-positive MC presence at baseline, but after treatment with cromolyn sodium (to block MC activation), these mice display reduced biliary damage/senescence, hepatic fibrosis, and inflammation. Aim: To determine the effects of INVA8001, a specific chymase inhibitor, on PSC phenotypes in Mdr2-/- mice. Methods: 10 wk male Mdr2-/- mice were treated with INVA8001 (20 mg/kg BW/day) for 14 days by daily IP injection. Serum, liver, cholangiocytes, and cholangiocyte supernatants were collected. FVB/NJ (wild-type, WT) and untreated Mdr2-/- mice were utilized for comparison. Liver damage was assessed by H&E staining in liver and total bile acids (TBAs) were measured in serum by EIA. Changes in intrahepatic bile duct mass (i.e., ductular reaction, DR) were determined by semiquantitative CK-19 immunohistochemistry (IHC) and biliary senescence by immunofluorescence (IF) for p16 (costained with CK-19) and qPCR for p16, p21, and p18 in total liver mRNA. Hepatic fibrosis and collagen deposition were evaluated by quantitative Fast Green/Sirius Red staining and qPCR for collagen type 1a and TIMP1 in total liver samples. MC presence was determined by staining for mouse MC protease-1 (marks chymase-positive MCs) and tryptase beta 2 (marks tryptase-positive MCs) and activation by HA serum content and qPCR for mMCP-1 and FCeR1 in total liver. Changes in senescence-associated secretory phenotypes (SASPs) were determined by serum TGF-β1 content using EIA and total liver expression by qPCR. Results: Inhibition with INVA8001 ameliorated DR, hepatic damage, senescence/SASP, and fibrosis along with chymase-positive MC infiltration and activation in Mdr2-/- mice compared to WT and untreated Mdr2-/- mice. Conclusion: Specific inhibition of chymase targets PSC phenotypes ameliorating pathogenesis by decreased biliary senescence and SASP factors. Our studies demonstrate the damaging effects of chymase-positive MCs in PSC and the therapeutic benefit of INVA8001 treatment with potential applicability to other liver diseases wherein MCs promote pathogenesis.

Fibrosis development is associated with poor prognosis in the patient with chronic liver disease. The formation of bridging fibrosis (BF) is a critical step for developing advanced fibrosis and further cirrhosis. Preventing BF formation could be a strategy for inhibiting further advancement of fibrosis to cirrhosis. For that, underpinning the mechanisms of BF formation is to crucial. We previously showed Wilms tumor 1 (WT1) is a transcriptional regulator of profibrogenic HAS2 in liver fibrosis. Here, we further identified a novel profibrogenic function of WT1 in hepatic stellate cell (HSC) activation and invasion that is associated with BF formation in liver fibrosis.
First, we identified WT1 expression is upregulated in HSCs of BF area in advanced fibrosis in NAFLD patients, which is determined by our new experiment by combining scRNA-seq and spatial transcriptome analysis. Because HSC invasion to liver parenchyma and collagen production is critical for BF formation, we investigated the molecular mechanisms of HSC invasion using a collagen hydrogel invasion model in vitro. We performed RNA-seq for non-invaded HSCs and HSCs during and after invasion by PDGF treatment in vitro. During the invasion, HSCs quickly acquired the capacity to express WT1 and HSCs showed much higher proliferative and fibrogenic phenotype after invasion compared to HSCs without invasion. This invasive, proliferative, and fibrogenic HSC phenotype was inhibited by WT1 deletion. Expectedly, HSC-specific WT1 knockout mice showed reduced HSC invasion and BF development in murine liver fibrosis models induced by bile duct ligation (BDL) and choline-deficient high fat diet (CD-HFD) feeding, concluding WT1 is a potent pro-fibrogenic factor. Then, we investigated the regulatory mechanism of WT1 induction. We found WT1 promoter contains hypoxia inducible factor (HIF) binding site and hypoxic challenge is a strong inducer of WT1 and HSC invasion. Furthermore, our bioinformatics analysis revealed that WT1 is the most enriched transcription factor for hypoxia-induced invasive phenotype in HSCs. As the downstream effectors of WT1, our RNA-seq analysis by comparing wild-type and HSC-specific WT1 knockout mice found PDGFRB and Cathepsin K (CTSK). CTSK is also upregulated by WT1 overexpression in HSCs. Pharmacological inhibition of CTSK inhibited HSC activation in vitro and prevented BF formation in the BDL model. In conclusion, the WT1-CTSK-mediated profibrogenic actions in HSCs are crucial for HSC invasion and BF formation in liver fibrosis. Thus, targeting the WT1-CTSK axis to suppress invasive HSCs could be a novel strategy to prevent BF formation in patient with chronic liver disease.

Saturday
Society: AASLD

Background: Chronic cholestatic liver diseases, such as primary sclerosing cholangitis (PSC), often lead to end-stage liver disease requiring liver transplantation. PSC also significantly increases the risk of cholangiocarcinoma (CCA). There is currently no effective therapeutic agent for PSC due to a limited understanding of its pathogenesis. Exosomes carry a variety of bioactive molecules, including miRNAs, lipids and proteins. The dysregulation of miRNAs is closely related to various pathological aspects of PSC. In this study, we aimed to investigate the expression profiles and function of exosomal miRNAs under cholestatic conditions.
Methods: One-year-old Mdr2-/- mice (FVB background) and age-/gender- matched wild-type (WT) mice were used in this study. The serum exosomes were isolated using qEV isolation system (from IZON). Total RNA was isolated from the serum exosomes and liver tissues using Trizol. Total RNA transcriptome was determined by RNAseq. The miRNA profiles in the exosomes and livers were analyzed using the NanoString nCounter® miRNA Expression panel. TargetScan and mirnet2.0 were used to identify the potential target genes. Protein-protein interaction (PPI) was constructed based on the STRING database. Hub genes under cholestatic conditions were visualized by Cytoscape software. The human CCA patient data were downloaded from the Cancer Genome Atlas (TCGA) database.
Results: Bioinformatic analysis identified 74 differentially expressed miRNAs (DE-miRs) and 137 DE-miRs in the male and female Mdr2-/- mice compared to corresponding WT controls, respectively. The identified DE-miRs were used to predict the target genes. GO and KEGG analysis further showed that these DE-miRs were linked to multiple signaling pathways related to cholestatic liver injury. We also identified 431 up-, and 1106 down- DE genes (DEGs) in the Mdr2-/- mice compared to WT mice. From the PPI network analysis of the DEGs, the top 100 hug genes were determined. We identified 11 upregulated DE-miRs in Mdr2-/- mice, which overlapped with the predicted miRs based on the the top 100 hug genes. Interestingly, among the overlapping DE-miRs, two miRs, miR-16 and let-7e, were also upregulated in the serum exosomes of Mdr2-/- mice. Among the 100 hug genes, we identified nine downregulated genes that were potential targets of miR-16 and let-7e. Further analysis of TCGA CCA data showed upregulation of miR-16 and let-7e, and 7 out of the 9 identified targeted genes were also significantly downregulated in CCA compared to healthy controls.
Conclusion: This study identified potential DE-miRs in the liver and serum exosomes which may contribute to cholestatic liver injury. This study supports the possible use of exosomal miRs as diagnostic and prognostic markers and therapeutic targets for cholestatic liver diseases.
<b>Fig 1. Liver DE-miRs and DEGs identification in Mdr2<sup>-/-</sup> mice compared to corresponding WT controls, target prediction and analysis of these DE-miRs and DEGs, and the overlapping miRNAs in cholestatic liver injury.</b><br /> (A)<b> </b>Liver DE-miRs expression profiles between male Mdr2<sup>-/-</sup> and WT controls. (B) Liver DE-miRs expression profiles between female Mdr2<sup>-/- </sup>and WT controls. (C)<b> </b>Liver DEGs expression profiles between Mdr2<sup>-/-</sup> and WT controls. (D) The top 50 hug genes of the PPI network of upregulated DEGs and the top 50 hug genes of the PPI network of downregulated DEGs. (E) Predicted network of miRNAs – 100 identified hug genes of DEGs between Mdr2<sup>-/- </sup>and WT controls. (F) Identification of 11 overlapping upregulated miRNAs in cholestatic liver injury. FC, fold change; miR, micro RNA. DE, differentially expressed, Mdr2<sup>-/-</sup> , multidrug resistance 2 gene knockout; WT, wild type.

Fig 1. Liver DE-miRs and DEGs identification in Mdr2-/- mice compared to corresponding WT controls, target prediction and analysis of these DE-miRs and DEGs, and the overlapping miRNAs in cholestatic liver injury.
(A) Liver DE-miRs expression profiles between male Mdr2-/- and WT controls. (B) Liver DE-miRs expression profiles between female Mdr2-/- and WT controls. (C) Liver DEGs expression profiles between Mdr2-/- and WT controls. (D) The top 50 hug genes of the PPI network of upregulated DEGs and the top 50 hug genes of the PPI network of downregulated DEGs. (E) Predicted network of miRNAs – 100 identified hug genes of DEGs between Mdr2-/- and WT controls. (F) Identification of 11 overlapping upregulated miRNAs in cholestatic liver injury. FC, fold change; miR, micro RNA. DE, differentially expressed, Mdr2-/- , multidrug resistance 2 gene knockout; WT, wild type.

<b>Fig 2. Exosome DE-miRs identification in Mdr2<sup>-/- </sup>mice compared to corresponding WT controls, the overlapping DE-miRs in the liver and serum exosomes, and comparison of the expression levels of these DE-miRs and target genes between normal and CHOL samples in TCGA CCA database.</b><br /> (A) Exosome DE-miRs expression profiles between female Mdr2<sup>-/-</sup> and WT controls. (B) Identification of 2 overlapping upregulated DE-miRs in the serum exosomes which may contribute to cholestatic liver injury. (C) The expression levels of these 2 overlapping upregulated DE-miRs between normal and CHOL samples. (D) Heat map, the expression levels of these target hug genes of 2 overlapping upregulated DE-miRs between normal and CHOL samples.

Fig 2. Exosome DE-miRs identification in Mdr2-/- mice compared to corresponding WT controls, the overlapping DE-miRs in the liver and serum exosomes, and comparison of the expression levels of these DE-miRs and target genes between normal and CHOL samples in TCGA CCA database.
(A) Exosome DE-miRs expression profiles between female Mdr2-/- and WT controls. (B) Identification of 2 overlapping upregulated DE-miRs in the serum exosomes which may contribute to cholestatic liver injury. (C) The expression levels of these 2 overlapping upregulated DE-miRs between normal and CHOL samples. (D) Heat map, the expression levels of these target hug genes of 2 overlapping upregulated DE-miRs between normal and CHOL samples.

Background: Following biliary injury/senescence in rodent models of cholestatic liver injury and in patients with PSC, mast cells (MCs) infiltrate the liver and migrate toward cholangiocytes. Proteases such as chymase and tryptase are indicative of MC origination and function, while activated MCs release histamine (HA) that promotes liver inflammation. In human PSC, chymase gene expression is significantly higher than tryptase in these patients. MC chymase induces detrimental effects in cardiac dysfunction, asthma, and lung fibrosis. In vivo, inhibition of chymase reverses acute liver failure and CCl4-induced damage. Similarly, in a PSC mouse model, Mdr2-/-, has increased chymase- and tryptase-positive MC presence at baseline, but after treatment with cromolyn sodium (to block MC activation), these mice display reduced biliary damage/senescence, hepatic fibrosis, and inflammation. Aim: To determine the effects of INVA8001, a specific chymase inhibitor, on PSC phenotypes in Mdr2-/- mice. Methods: 10 wk male Mdr2-/- mice were treated with INVA8001 (20 mg/kg BW/day) for 14 days by daily IP injection. Serum, liver, cholangiocytes, and cholangiocyte supernatants were collected. FVB/NJ (wild-type, WT) and untreated Mdr2-/- mice were utilized for comparison. Liver damage was assessed by H&E staining in liver and total bile acids (TBAs) were measured in serum by EIA. Changes in intrahepatic bile duct mass (i.e., ductular reaction, DR) were determined by semiquantitative CK-19 immunohistochemistry (IHC) and biliary senescence by immunofluorescence (IF) for p16 (costained with CK-19) and qPCR for p16, p21, and p18 in total liver mRNA. Hepatic fibrosis and collagen deposition were evaluated by quantitative Fast Green/Sirius Red staining and qPCR for collagen type 1a and TIMP1 in total liver samples. MC presence was determined by staining for mouse MC protease-1 (marks chymase-positive MCs) and tryptase beta 2 (marks tryptase-positive MCs) and activation by HA serum content and qPCR for mMCP-1 and FCeR1 in total liver. Changes in senescence-associated secretory phenotypes (SASPs) were determined by serum TGF-β1 content using EIA and total liver expression by qPCR. Results: Inhibition with INVA8001 ameliorated DR, hepatic damage, senescence/SASP, and fibrosis along with chymase-positive MC infiltration and activation in Mdr2-/- mice compared to WT and untreated Mdr2-/- mice. Conclusion: Specific inhibition of chymase targets PSC phenotypes ameliorating pathogenesis by decreased biliary senescence and SASP factors. Our studies demonstrate the damaging effects of chymase-positive MCs in PSC and the therapeutic benefit of INVA8001 treatment with potential applicability to other liver diseases wherein MCs promote pathogenesis.

Fibrosis development is associated with poor prognosis in the patient with chronic liver disease. The formation of bridging fibrosis (BF) is a critical step for developing advanced fibrosis and further cirrhosis. Preventing BF formation could be a strategy for inhibiting further advancement of fibrosis to cirrhosis. For that, underpinning the mechanisms of BF formation is to crucial. We previously showed Wilms tumor 1 (WT1) is a transcriptional regulator of profibrogenic HAS2 in liver fibrosis. Here, we further identified a novel profibrogenic function of WT1 in hepatic stellate cell (HSC) activation and invasion that is associated with BF formation in liver fibrosis.
First, we identified WT1 expression is upregulated in HSCs of BF area in advanced fibrosis in NAFLD patients, which is determined by our new experiment by combining scRNA-seq and spatial transcriptome analysis. Because HSC invasion to liver parenchyma and collagen production is critical for BF formation, we investigated the molecular mechanisms of HSC invasion using a collagen hydrogel invasion model in vitro. We performed RNA-seq for non-invaded HSCs and HSCs during and after invasion by PDGF treatment in vitro. During the invasion, HSCs quickly acquired the capacity to express WT1 and HSCs showed much higher proliferative and fibrogenic phenotype after invasion compared to HSCs without invasion. This invasive, proliferative, and fibrogenic HSC phenotype was inhibited by WT1 deletion. Expectedly, HSC-specific WT1 knockout mice showed reduced HSC invasion and BF development in murine liver fibrosis models induced by bile duct ligation (BDL) and choline-deficient high fat diet (CD-HFD) feeding, concluding WT1 is a potent pro-fibrogenic factor. Then, we investigated the regulatory mechanism of WT1 induction. We found WT1 promoter contains hypoxia inducible factor (HIF) binding site and hypoxic challenge is a strong inducer of WT1 and HSC invasion. Furthermore, our bioinformatics analysis revealed that WT1 is the most enriched transcription factor for hypoxia-induced invasive phenotype in HSCs. As the downstream effectors of WT1, our RNA-seq analysis by comparing wild-type and HSC-specific WT1 knockout mice found PDGFRB and Cathepsin K (CTSK). CTSK is also upregulated by WT1 overexpression in HSCs. Pharmacological inhibition of CTSK inhibited HSC activation in vitro and prevented BF formation in the BDL model. In conclusion, the WT1-CTSK-mediated profibrogenic actions in HSCs are crucial for HSC invasion and BF formation in liver fibrosis. Thus, targeting the WT1-CTSK axis to suppress invasive HSCs could be a novel strategy to prevent BF formation in patient with chronic liver disease.
Background: Cholestatic liver disease can lead to endothelial dysfunction and dedifferentiation of liver sinusoidal endothelial cells (LSECs) with loss of fenestrations, deposition of a basement membrane, and surface expression of CD31 and CD34, a process that has been termed sinusoidal capillarization and that precedes liver fibrosis. We aimed to define the microRNA regulated vascular remodeling, intussusceptive angiogenesis, and liver fibrosis during cholestatic liver injury.
Methods: To demonstrate the overall ultrastructure of the vascular damage during cholestatic liver injury, we injected mice via the portal vein with resin to create vascular corrosion casts of the liver with BDL in miR-34a knockout and WT control mice for scanning electron microscopy analysis. CD34+ cells were isolated from mouse liver using laser capture microdissection (LCM). A capture probe covalently bound to an oligonucleotide containing biotin and a color-coded reporter probe were designed for 84 endothelial function-related genes and analyzed with the nCounter Single Cell Gene Expression Assay.
Results: Using BDL mouse model of cholestatic liver injury to evaluate vascular injury and deranged angioarchitecture of the liver by 3-dimensional morphology of the hepatic microcirculation, results showed that BDL induced extensive remodeling of the sinusoids with a plexus-like appearance. Casts revealed pores and endovascular pillars, the corresponding intraluminal structures to the pores of intussusception, the hallmark of intussusceptive angiogenesis after vascular injuries. The process of vascular injury associated angiogenesis, vascular remodeling and rearrangement after BDL led to an increased variation of the sinusoidal diameter and increased branching within the microcirculation. Lack of miR-34a in vivo reversed the serum ALT level, and restored the levels of Sirt1 coupled with decreased NOS3 expression as well as the reduced levels of TNFα, CCl2, IL-1β, IFNβ and IL-7 in LCM isolated CD34+ cells analyzed by nCounter single cell gene expression assay. Depletion of miR-34a in vivo also induced a significant down-regulation of profibrogenic genes and MMPs in total liver tissues and LCM isolated CD34+ cells by single cell gene assay from BDL mice liver, along with the reduced vascular remodeling and intussusceptive angiogenesis.
Conclusion: By 3-dimensional morphology of the hepatic microcirculation and single cell analysis, our discovery that microRNA-34a as an important signaling pathway in hepatic vascular endothelium that governs vascular structure and function in the liver, regulates intussusceptive angiogenesis, and contributes to liver fibrosis during cholestatic liver injury implicates an exciting field in which the epigenomic microRNAs of endothelial dysfunction may be manipulated with potential therapeutic benefits.

Saturday
Society: AASLD

Background: Chronic cholestatic liver diseases, such as primary sclerosing cholangitis (PSC), often lead to end-stage liver disease requiring liver transplantation. PSC also significantly increases the risk of cholangiocarcinoma (CCA). There is currently no effective therapeutic agent for PSC due to a limited understanding of its pathogenesis. Exosomes carry a variety of bioactive molecules, including miRNAs, lipids and proteins. The dysregulation of miRNAs is closely related to various pathological aspects of PSC. In this study, we aimed to investigate the expression profiles and function of exosomal miRNAs under cholestatic conditions.
Methods: One-year-old Mdr2-/- mice (FVB background) and age-/gender- matched wild-type (WT) mice were used in this study. The serum exosomes were isolated using qEV isolation system (from IZON). Total RNA was isolated from the serum exosomes and liver tissues using Trizol. Total RNA transcriptome was determined by RNAseq. The miRNA profiles in the exosomes and livers were analyzed using the NanoString nCounter® miRNA Expression panel. TargetScan and mirnet2.0 were used to identify the potential target genes. Protein-protein interaction (PPI) was constructed based on the STRING database. Hub genes under cholestatic conditions were visualized by Cytoscape software. The human CCA patient data were downloaded from the Cancer Genome Atlas (TCGA) database.
Results: Bioinformatic analysis identified 74 differentially expressed miRNAs (DE-miRs) and 137 DE-miRs in the male and female Mdr2-/- mice compared to corresponding WT controls, respectively. The identified DE-miRs were used to predict the target genes. GO and KEGG analysis further showed that these DE-miRs were linked to multiple signaling pathways related to cholestatic liver injury. We also identified 431 up-, and 1106 down- DE genes (DEGs) in the Mdr2-/- mice compared to WT mice. From the PPI network analysis of the DEGs, the top 100 hug genes were determined. We identified 11 upregulated DE-miRs in Mdr2-/- mice, which overlapped with the predicted miRs based on the the top 100 hug genes. Interestingly, among the overlapping DE-miRs, two miRs, miR-16 and let-7e, were also upregulated in the serum exosomes of Mdr2-/- mice. Among the 100 hug genes, we identified nine downregulated genes that were potential targets of miR-16 and let-7e. Further analysis of TCGA CCA data showed upregulation of miR-16 and let-7e, and 7 out of the 9 identified targeted genes were also significantly downregulated in CCA compared to healthy controls.
Conclusion: This study identified potential DE-miRs in the liver and serum exosomes which may contribute to cholestatic liver injury. This study supports the possible use of exosomal miRs as diagnostic and prognostic markers and therapeutic targets for cholestatic liver diseases.
<b>Fig 1. Liver DE-miRs and DEGs identification in Mdr2<sup>-/-</sup> mice compared to corresponding WT controls, target prediction and analysis of these DE-miRs and DEGs, and the overlapping miRNAs in cholestatic liver injury.</b><br /> (A)<b> </b>Liver DE-miRs expression profiles between male Mdr2<sup>-/-</sup> and WT controls. (B) Liver DE-miRs expression profiles between female Mdr2<sup>-/- </sup>and WT controls. (C)<b> </b>Liver DEGs expression profiles between Mdr2<sup>-/-</sup> and WT controls. (D) The top 50 hug genes of the PPI network of upregulated DEGs and the top 50 hug genes of the PPI network of downregulated DEGs. (E) Predicted network of miRNAs – 100 identified hug genes of DEGs between Mdr2<sup>-/- </sup>and WT controls. (F) Identification of 11 overlapping upregulated miRNAs in cholestatic liver injury. FC, fold change; miR, micro RNA. DE, differentially expressed, Mdr2<sup>-/-</sup> , multidrug resistance 2 gene knockout; WT, wild type.

Fig 1. Liver DE-miRs and DEGs identification in Mdr2-/- mice compared to corresponding WT controls, target prediction and analysis of these DE-miRs and DEGs, and the overlapping miRNAs in cholestatic liver injury.
(A) Liver DE-miRs expression profiles between male Mdr2-/- and WT controls. (B) Liver DE-miRs expression profiles between female Mdr2-/- and WT controls. (C) Liver DEGs expression profiles between Mdr2-/- and WT controls. (D) The top 50 hug genes of the PPI network of upregulated DEGs and the top 50 hug genes of the PPI network of downregulated DEGs. (E) Predicted network of miRNAs – 100 identified hug genes of DEGs between Mdr2-/- and WT controls. (F) Identification of 11 overlapping upregulated miRNAs in cholestatic liver injury. FC, fold change; miR, micro RNA. DE, differentially expressed, Mdr2-/- , multidrug resistance 2 gene knockout; WT, wild type.

<b>Fig 2. Exosome DE-miRs identification in Mdr2<sup>-/- </sup>mice compared to corresponding WT controls, the overlapping DE-miRs in the liver and serum exosomes, and comparison of the expression levels of these DE-miRs and target genes between normal and CHOL samples in TCGA CCA database.</b><br /> (A) Exosome DE-miRs expression profiles between female Mdr2<sup>-/-</sup> and WT controls. (B) Identification of 2 overlapping upregulated DE-miRs in the serum exosomes which may contribute to cholestatic liver injury. (C) The expression levels of these 2 overlapping upregulated DE-miRs between normal and CHOL samples. (D) Heat map, the expression levels of these target hug genes of 2 overlapping upregulated DE-miRs between normal and CHOL samples.

Fig 2. Exosome DE-miRs identification in Mdr2-/- mice compared to corresponding WT controls, the overlapping DE-miRs in the liver and serum exosomes, and comparison of the expression levels of these DE-miRs and target genes between normal and CHOL samples in TCGA CCA database.
(A) Exosome DE-miRs expression profiles between female Mdr2-/- and WT controls. (B) Identification of 2 overlapping upregulated DE-miRs in the serum exosomes which may contribute to cholestatic liver injury. (C) The expression levels of these 2 overlapping upregulated DE-miRs between normal and CHOL samples. (D) Heat map, the expression levels of these target hug genes of 2 overlapping upregulated DE-miRs between normal and CHOL samples.

Background: Following biliary injury/senescence in rodent models of cholestatic liver injury and in patients with PSC, mast cells (MCs) infiltrate the liver and migrate toward cholangiocytes. Proteases such as chymase and tryptase are indicative of MC origination and function, while activated MCs release histamine (HA) that promotes liver inflammation. In human PSC, chymase gene expression is significantly higher than tryptase in these patients. MC chymase induces detrimental effects in cardiac dysfunction, asthma, and lung fibrosis. In vivo, inhibition of chymase reverses acute liver failure and CCl4-induced damage. Similarly, in a PSC mouse model, Mdr2-/-, has increased chymase- and tryptase-positive MC presence at baseline, but after treatment with cromolyn sodium (to block MC activation), these mice display reduced biliary damage/senescence, hepatic fibrosis, and inflammation. Aim: To determine the effects of INVA8001, a specific chymase inhibitor, on PSC phenotypes in Mdr2-/- mice. Methods: 10 wk male Mdr2-/- mice were treated with INVA8001 (20 mg/kg BW/day) for 14 days by daily IP injection. Serum, liver, cholangiocytes, and cholangiocyte supernatants were collected. FVB/NJ (wild-type, WT) and untreated Mdr2-/- mice were utilized for comparison. Liver damage was assessed by H&E staining in liver and total bile acids (TBAs) were measured in serum by EIA. Changes in intrahepatic bile duct mass (i.e., ductular reaction, DR) were determined by semiquantitative CK-19 immunohistochemistry (IHC) and biliary senescence by immunofluorescence (IF) for p16 (costained with CK-19) and qPCR for p16, p21, and p18 in total liver mRNA. Hepatic fibrosis and collagen deposition were evaluated by quantitative Fast Green/Sirius Red staining and qPCR for collagen type 1a and TIMP1 in total liver samples. MC presence was determined by staining for mouse MC protease-1 (marks chymase-positive MCs) and tryptase beta 2 (marks tryptase-positive MCs) and activation by HA serum content and qPCR for mMCP-1 and FCeR1 in total liver. Changes in senescence-associated secretory phenotypes (SASPs) were determined by serum TGF-β1 content using EIA and total liver expression by qPCR. Results: Inhibition with INVA8001 ameliorated DR, hepatic damage, senescence/SASP, and fibrosis along with chymase-positive MC infiltration and activation in Mdr2-/- mice compared to WT and untreated Mdr2-/- mice. Conclusion: Specific inhibition of chymase targets PSC phenotypes ameliorating pathogenesis by decreased biliary senescence and SASP factors. Our studies demonstrate the damaging effects of chymase-positive MCs in PSC and the therapeutic benefit of INVA8001 treatment with potential applicability to other liver diseases wherein MCs promote pathogenesis.

Fibrosis development is associated with poor prognosis in the patient with chronic liver disease. The formation of bridging fibrosis (BF) is a critical step for developing advanced fibrosis and further cirrhosis. Preventing BF formation could be a strategy for inhibiting further advancement of fibrosis to cirrhosis. For that, underpinning the mechanisms of BF formation is to crucial. We previously showed Wilms tumor 1 (WT1) is a transcriptional regulator of profibrogenic HAS2 in liver fibrosis. Here, we further identified a novel profibrogenic function of WT1 in hepatic stellate cell (HSC) activation and invasion that is associated with BF formation in liver fibrosis.
First, we identified WT1 expression is upregulated in HSCs of BF area in advanced fibrosis in NAFLD patients, which is determined by our new experiment by combining scRNA-seq and spatial transcriptome analysis. Because HSC invasion to liver parenchyma and collagen production is critical for BF formation, we investigated the molecular mechanisms of HSC invasion using a collagen hydrogel invasion model in vitro. We performed RNA-seq for non-invaded HSCs and HSCs during and after invasion by PDGF treatment in vitro. During the invasion, HSCs quickly acquired the capacity to express WT1 and HSCs showed much higher proliferative and fibrogenic phenotype after invasion compared to HSCs without invasion. This invasive, proliferative, and fibrogenic HSC phenotype was inhibited by WT1 deletion. Expectedly, HSC-specific WT1 knockout mice showed reduced HSC invasion and BF development in murine liver fibrosis models induced by bile duct ligation (BDL) and choline-deficient high fat diet (CD-HFD) feeding, concluding WT1 is a potent pro-fibrogenic factor. Then, we investigated the regulatory mechanism of WT1 induction. We found WT1 promoter contains hypoxia inducible factor (HIF) binding site and hypoxic challenge is a strong inducer of WT1 and HSC invasion. Furthermore, our bioinformatics analysis revealed that WT1 is the most enriched transcription factor for hypoxia-induced invasive phenotype in HSCs. As the downstream effectors of WT1, our RNA-seq analysis by comparing wild-type and HSC-specific WT1 knockout mice found PDGFRB and Cathepsin K (CTSK). CTSK is also upregulated by WT1 overexpression in HSCs. Pharmacological inhibition of CTSK inhibited HSC activation in vitro and prevented BF formation in the BDL model. In conclusion, the WT1-CTSK-mediated profibrogenic actions in HSCs are crucial for HSC invasion and BF formation in liver fibrosis. Thus, targeting the WT1-CTSK axis to suppress invasive HSCs could be a novel strategy to prevent BF formation in patient with chronic liver disease.
Background: Cholestatic liver disease can lead to endothelial dysfunction and dedifferentiation of liver sinusoidal endothelial cells (LSECs) with loss of fenestrations, deposition of a basement membrane, and surface expression of CD31 and CD34, a process that has been termed sinusoidal capillarization and that precedes liver fibrosis. We aimed to define the microRNA regulated vascular remodeling, intussusceptive angiogenesis, and liver fibrosis during cholestatic liver injury.
Methods: To demonstrate the overall ultrastructure of the vascular damage during cholestatic liver injury, we injected mice via the portal vein with resin to create vascular corrosion casts of the liver with BDL in miR-34a knockout and WT control mice for scanning electron microscopy analysis. CD34+ cells were isolated from mouse liver using laser capture microdissection (LCM). A capture probe covalently bound to an oligonucleotide containing biotin and a color-coded reporter probe were designed for 84 endothelial function-related genes and analyzed with the nCounter Single Cell Gene Expression Assay.
Results: Using BDL mouse model of cholestatic liver injury to evaluate vascular injury and deranged angioarchitecture of the liver by 3-dimensional morphology of the hepatic microcirculation, results showed that BDL induced extensive remodeling of the sinusoids with a plexus-like appearance. Casts revealed pores and endovascular pillars, the corresponding intraluminal structures to the pores of intussusception, the hallmark of intussusceptive angiogenesis after vascular injuries. The process of vascular injury associated angiogenesis, vascular remodeling and rearrangement after BDL led to an increased variation of the sinusoidal diameter and increased branching within the microcirculation. Lack of miR-34a in vivo reversed the serum ALT level, and restored the levels of Sirt1 coupled with decreased NOS3 expression as well as the reduced levels of TNFα, CCl2, IL-1β, IFNβ and IL-7 in LCM isolated CD34+ cells analyzed by nCounter single cell gene expression assay. Depletion of miR-34a in vivo also induced a significant down-regulation of profibrogenic genes and MMPs in total liver tissues and LCM isolated CD34+ cells by single cell gene assay from BDL mice liver, along with the reduced vascular remodeling and intussusceptive angiogenesis.
Conclusion: By 3-dimensional morphology of the hepatic microcirculation and single cell analysis, our discovery that microRNA-34a as an important signaling pathway in hepatic vascular endothelium that governs vascular structure and function in the liver, regulates intussusceptive angiogenesis, and contributes to liver fibrosis during cholestatic liver injury implicates an exciting field in which the epigenomic microRNAs of endothelial dysfunction may be manipulated with potential therapeutic benefits.
Background: Growth hormone (GH) and GH receptor (GHR) signaling regulates cell growth and promotes liver regeneration. GH activates downstream insulin-like growth factor 1 (IGF1) and its receptor (IGF1R) signaling, and GH and IGF1 promote cholangiocyte proliferation. We have previously demonstrated that downregulation of microRNA let-7 leads to cholangiocyte proliferation and ductular reaction. We hypothesize that upregulation of GH/GHR signaling in liver diseases induces robust cholangiocyte proliferation leading to ductular reaction, which is associated with liver fibrosis via downregulated let-7.
Methods: Human liver sections of healthy donors and patients with primary sclerosing cholangitis (PSC), primary biliary cholangitis (PBC), biliary atresia, NAFLD, non-alcoholic steatohepatitis (NASH), or alcoholic steatohepatitis (ASH) were analyzed by CK-19 immunohistochemistry (IHC) to detect ductular reaction, Sirius Red staining to determine liver fibrosis, and GHR IHC. Patients’ liver sections were also used for double immunofluorescence staining to identify GHR or IGF1R expression in CK-19+ cholangiocytes. Mdr2-/- mice (PSC model, female, 12-wk old) were administered with vehicle (1×PBS), human recombinant GH (hrGH, 0.6 µg/g body weight/day) or an FDA-approved GHR antagonist (Somavert, 18 µg/g body weight/day) for 2 wks via implanted osmotic minipumps. Liver tissues were characterized by H&E, CK-19 IHC, and Sirius Red staining. RT-PCR was performed for human PSC cholangiocytes or primary murine cholangiocytes isolated from Mdr2-/- mice after treatments to determine expression levels of let-7.
Results: Patients with PSC, PBC, biliary atresia, NASH, or ASH showed extensive ductular reaction and liver fibrosis, as well as elevated immunoreactivity against GHR in the portal area compared to healthy individuals. The NAFLD patient showed only mild ductular reaction and liver fibrosis without elevated GHR immunoreactivity. Elevated expression of GHR and IGF1R was observed in CK-19+ cholangiocytes of PSC, PBC, and NASH patients. Administration of hrGH exacerbated, but Somavert attenuated liver damage, portal infiltration, ductular reaction, and liver fibrosis in Mdr2-/- mice compared to vehicle control. Expression levels of let-7 were downregulated in PSC cholangiocytes compared to control cholangiocytes. Target prediction showed that let-7 families might inhibit expression of GHR, IGF1, and IGF1R. Treatments of hrGH decreases let-7 expression in cholangiocytes in vivo, showing the association of the GH/GHR axis with liver fibrosis via downregulation of let-7 and upregulation of cholangiocyte proliferation via IGF1 signaling.
Conclusion: GH/IGF1 signaling is associated with liver fibrosis in liver diseases with extensive ductular reaction. Blocking GH/GHR signaling using Somavert could be a promising therapeutic approach for liver fibrosis.

09:00am - 10:30am EDT - May 6, 2023 | Room: S105a (McCormick Place)
Ashwani Singal, Moderator; Elliot Tapper, Moderator
Society: AGA
Type: Research Forum
Society: AGA


Saturday
09:00am - 09:15am EDT - May 6, 2023 | Room: S105a (McCormick Place)
Society: AGA
Type: Research Forum
Society: AGA

Background: Hepatic encephalopathy (HE) is associated with increased mortality, falls, and frequent hospitalizations. Patient reported outcomes (PROs) are useful tools to assess health-related quality of life (HRQOL) measures such as impairment of sleep, cognition, or activity. PROs have also been shown to be reliable & valid tools to detect early signs of HE. Many clinicians initiate lactulose when patients present with poor PROs without cognitive testing, however data are limited regarding the efficacy of this strategy.
Methods: The Mi-Kristal trial is a single-center, randomized study to determine whether a 28-day regimen of Kristalose®, a crystalline lactulose therapy (20g BID) improves HRQOL in people with poor PROs. We enrolled patients with cirrhosis, portal hypertension, no prior HE, & Activity Impairment attributed to cirrhosis >3 (scale 0-10) because this score was highly predictive of overt HE in prior studies. Endpoints included the short form-8 (SF-8), animal naming test (ANT), falls, and a 4-point Likert scale rating sleep quality (very bad to very good).
Results: Fifty-six subjects were randomized, 52 subjects completed the protocol; 25 Kristalose and 27 no treatment. Median Baseline MELD-Na was 11 and ANT was 19 without differences between the groups at baseline. At Day 28 no significant difference was observed using the SF-8: subjects on Kristalose had an 8.1 point increase (95%CI 3.7-12.4) compared to 6.6 (95%CI 2.3-10.8) in control (p=0.6). Significant improvements were observed in subjects on Kristalose using the ANT which increased by 3.7 (95%CI 2.1-5.4) vs control - -0.2 (95%CI -1.7-1.4); 32% on Kristalose had a 5-point increase in ANT vs 11% of control. Falls were reported by 11% in control and 4% on Kristalose. At the end of the trial, 92% on Kristalose reported good sleep compared to 52% of control. Compared to control, Kristalose was associated with a significant 0.6 (95%CI0.3-1.0) point improvement in sleep quality and a significant 1.7 (95%CI0.3-3.1) point decrease in activity impairment.
Conclusion: Among patients with activity impairment at risk for HE, a 28-day crystalline lactulose regimen led to improved sleep, cognitive function & activity impairment. No significant difference in HRQOL was observed using the SF-8 possibly because the instrument is insensitive to change in this context or a longer treatment duration is required. A 6-month trial is planned. Our findings support the use of PROs to assess for benefit of HE-therapy and that early treatment improves select PROs.

Saturday
Society: AGA

Background: Hepatic encephalopathy (HE) is associated with increased mortality, falls, and frequent hospitalizations. Patient reported outcomes (PROs) are useful tools to assess health-related quality of life (HRQOL) measures such as impairment of sleep, cognition, or activity. PROs have also been shown to be reliable & valid tools to detect early signs of HE. Many clinicians initiate lactulose when patients present with poor PROs without cognitive testing, however data are limited regarding the efficacy of this strategy.
Methods: The Mi-Kristal trial is a single-center, randomized study to determine whether a 28-day regimen of Kristalose®, a crystalline lactulose therapy (20g BID) improves HRQOL in people with poor PROs. We enrolled patients with cirrhosis, portal hypertension, no prior HE, & Activity Impairment attributed to cirrhosis >3 (scale 0-10) because this score was highly predictive of overt HE in prior studies. Endpoints included the short form-8 (SF-8), animal naming test (ANT), falls, and a 4-point Likert scale rating sleep quality (very bad to very good).
Results: Fifty-six subjects were randomized, 52 subjects completed the protocol; 25 Kristalose and 27 no treatment. Median Baseline MELD-Na was 11 and ANT was 19 without differences between the groups at baseline. At Day 28 no significant difference was observed using the SF-8: subjects on Kristalose had an 8.1 point increase (95%CI 3.7-12.4) compared to 6.6 (95%CI 2.3-10.8) in control (p=0.6). Significant improvements were observed in subjects on Kristalose using the ANT which increased by 3.7 (95%CI 2.1-5.4) vs control - -0.2 (95%CI -1.7-1.4); 32% on Kristalose had a 5-point increase in ANT vs 11% of control. Falls were reported by 11% in control and 4% on Kristalose. At the end of the trial, 92% on Kristalose reported good sleep compared to 52% of control. Compared to control, Kristalose was associated with a significant 0.6 (95%CI0.3-1.0) point improvement in sleep quality and a significant 1.7 (95%CI0.3-3.1) point decrease in activity impairment.
Conclusion: Among patients with activity impairment at risk for HE, a 28-day crystalline lactulose regimen led to improved sleep, cognitive function & activity impairment. No significant difference in HRQOL was observed using the SF-8 possibly because the instrument is insensitive to change in this context or a longer treatment duration is required. A 6-month trial is planned. Our findings support the use of PROs to assess for benefit of HE-therapy and that early treatment improves select PROs.
Background
Endoscopic “palpation” of the liver is possible via endoscopic ultrasound (EUS). Regardless of body habitus, the EUS probe can be reproducibly positioned close to the liver surface. With a standard turn of the big wheel, the EUS probe indents the liver surface, and the level of indentation can be measured with sonographic calipers. Our hypothesis is that a fibrotic liver is harder to indent and the degree of indentation correlates with liver fibrosis severity. We aim to correlate EUS liver palpation with histology in patients with NAFLD and compare its predictive value for fibrosis staging to more conventional screening methods.
Methods
This was a cross sectional study of prospectively collected data. Consecutive patients at 3 hospitals between June 2021 and Nov 2022 underwent EUS liver palpation with subsequent liver biopsy. Index scores of Fibrosis-4 Index (FIB-4), AST to Platelet Ratio Index (APRI), NAFLD Fibrosis Score (NFS), and Agile 3+/4 per transient elastography (TE, i.e. Fibroscan) were calculated. Comparisons between EUS liver palpation and index scores/TE were performed using area under the curve (AUC) analysis.
Results
61 patients were evaluated. The mean age was 50. 64.5% were female. Average BMI was 41.2. EUS liver palpation significantly correlated with fibrosis stage on liver biopsy (p=0.0002) with lower indentation values at higher fibrosis stages [Figure 1A]. EUS palpation had AUC of 0.73, 0.80, and 0.98 for discriminating significant fibrosis (F0-1 vs F2-4), advanced fibrosis (F0-2 vs F3-4), and cirrhosis (F0-3 vs F4) respectively [Figure 1B]. EUS liver palpation was superior to APRI and NFS in predicting cirrhosis (p=0.004 and 0.038 respectively).. Indentation of ≤3.5mm yields sensitivity, specificity, positive predictive value, and negative predictive value of 64.7%, 100%, 100%, and 88% respectively for detecting advanced fibrosis.
35/61 (57%) patients had TE performed. In this sub-cohort, EUS palpation had higher AUC values than TE and Agile 3+/4 but this was not significantly different [Figure 2A]. Combination of palpation + Agile 3+/4 for advanced fibrosis and cirrhosis cutoffs were superior to TE alone (p=0.0018 and 0.017 respectively). Lastly, we discovered body mass index (BMI) may be a confounder for TE (Pearson coefficient r=0.70, p=0.0005) but not for EUS liver indentation (r=-0.30, p=0.062) [Figure 2B].
Conclusions
EUS liver palpation is a reliable, novel, and easy-to-use tool to screen for advanced fibrosis in patients with NAFLD, and may be superior to APRI and NFS in predicting cirrhosis. This can be useful in patients with obesity in which an elevated BMI may confound TE results, and may be a valuable minimally invasive tool for endohepatologists in liver fibrosis screening for the NAFLD population. Larger multicenter studies will help to better define the utility and reproducibility of EUS liver palpation.

Saturday
Society: AGA

Background: Hepatic encephalopathy (HE) is associated with increased mortality, falls, and frequent hospitalizations. Patient reported outcomes (PROs) are useful tools to assess health-related quality of life (HRQOL) measures such as impairment of sleep, cognition, or activity. PROs have also been shown to be reliable & valid tools to detect early signs of HE. Many clinicians initiate lactulose when patients present with poor PROs without cognitive testing, however data are limited regarding the efficacy of this strategy.
Methods: The Mi-Kristal trial is a single-center, randomized study to determine whether a 28-day regimen of Kristalose®, a crystalline lactulose therapy (20g BID) improves HRQOL in people with poor PROs. We enrolled patients with cirrhosis, portal hypertension, no prior HE, & Activity Impairment attributed to cirrhosis >3 (scale 0-10) because this score was highly predictive of overt HE in prior studies. Endpoints included the short form-8 (SF-8), animal naming test (ANT), falls, and a 4-point Likert scale rating sleep quality (very bad to very good).
Results: Fifty-six subjects were randomized, 52 subjects completed the protocol; 25 Kristalose and 27 no treatment. Median Baseline MELD-Na was 11 and ANT was 19 without differences between the groups at baseline. At Day 28 no significant difference was observed using the SF-8: subjects on Kristalose had an 8.1 point increase (95%CI 3.7-12.4) compared to 6.6 (95%CI 2.3-10.8) in control (p=0.6). Significant improvements were observed in subjects on Kristalose using the ANT which increased by 3.7 (95%CI 2.1-5.4) vs control - -0.2 (95%CI -1.7-1.4); 32% on Kristalose had a 5-point increase in ANT vs 11% of control. Falls were reported by 11% in control and 4% on Kristalose. At the end of the trial, 92% on Kristalose reported good sleep compared to 52% of control. Compared to control, Kristalose was associated with a significant 0.6 (95%CI0.3-1.0) point improvement in sleep quality and a significant 1.7 (95%CI0.3-3.1) point decrease in activity impairment.
Conclusion: Among patients with activity impairment at risk for HE, a 28-day crystalline lactulose regimen led to improved sleep, cognitive function & activity impairment. No significant difference in HRQOL was observed using the SF-8 possibly because the instrument is insensitive to change in this context or a longer treatment duration is required. A 6-month trial is planned. Our findings support the use of PROs to assess for benefit of HE-therapy and that early treatment improves select PROs.
Background
Endoscopic “palpation” of the liver is possible via endoscopic ultrasound (EUS). Regardless of body habitus, the EUS probe can be reproducibly positioned close to the liver surface. With a standard turn of the big wheel, the EUS probe indents the liver surface, and the level of indentation can be measured with sonographic calipers. Our hypothesis is that a fibrotic liver is harder to indent and the degree of indentation correlates with liver fibrosis severity. We aim to correlate EUS liver palpation with histology in patients with NAFLD and compare its predictive value for fibrosis staging to more conventional screening methods.
Methods
This was a cross sectional study of prospectively collected data. Consecutive patients at 3 hospitals between June 2021 and Nov 2022 underwent EUS liver palpation with subsequent liver biopsy. Index scores of Fibrosis-4 Index (FIB-4), AST to Platelet Ratio Index (APRI), NAFLD Fibrosis Score (NFS), and Agile 3+/4 per transient elastography (TE, i.e. Fibroscan) were calculated. Comparisons between EUS liver palpation and index scores/TE were performed using area under the curve (AUC) analysis.
Results
61 patients were evaluated. The mean age was 50. 64.5% were female. Average BMI was 41.2. EUS liver palpation significantly correlated with fibrosis stage on liver biopsy (p=0.0002) with lower indentation values at higher fibrosis stages [Figure 1A]. EUS palpation had AUC of 0.73, 0.80, and 0.98 for discriminating significant fibrosis (F0-1 vs F2-4), advanced fibrosis (F0-2 vs F3-4), and cirrhosis (F0-3 vs F4) respectively [Figure 1B]. EUS liver palpation was superior to APRI and NFS in predicting cirrhosis (p=0.004 and 0.038 respectively).. Indentation of ≤3.5mm yields sensitivity, specificity, positive predictive value, and negative predictive value of 64.7%, 100%, 100%, and 88% respectively for detecting advanced fibrosis.
35/61 (57%) patients had TE performed. In this sub-cohort, EUS palpation had higher AUC values than TE and Agile 3+/4 but this was not significantly different [Figure 2A]. Combination of palpation + Agile 3+/4 for advanced fibrosis and cirrhosis cutoffs were superior to TE alone (p=0.0018 and 0.017 respectively). Lastly, we discovered body mass index (BMI) may be a confounder for TE (Pearson coefficient r=0.70, p=0.0005) but not for EUS liver indentation (r=-0.30, p=0.062) [Figure 2B].
Conclusions
EUS liver palpation is a reliable, novel, and easy-to-use tool to screen for advanced fibrosis in patients with NAFLD, and may be superior to APRI and NFS in predicting cirrhosis. This can be useful in patients with obesity in which an elevated BMI may confound TE results, and may be a valuable minimally invasive tool for endohepatologists in liver fibrosis screening for the NAFLD population. Larger multicenter studies will help to better define the utility and reproducibility of EUS liver palpation.
Background: There is high prevalence of metabolic co-morbidities among U.S. veterans, and hence a high prevalence of metabolic dysfunction associated fatty liver disease (MAFLD). The long-term incidence of cirrhosis among veterans with MAFLD has not been well studied. We aimed to evaluate the overall risk of cirrhosis as well as disparities in cirrhosis incidence among a national cohort of U.S. Veterans with MAFLD.
Methods: We retrospectively evaluated the Veterans Affairs Corporate Data Warehouse from 2010-2021, which captures data on veterans receiving health care across the U.S. MAFLD was identified using established definitions: presence of hepatic steatosis (defined by hepatic steatosis index >36) plus >1 of the following: 1) body mass index >25 kg/m2 in non-Asians or >23 kg/m2 in Asians, 2) concurrent diabetes mellitus, or 3) >2 metabolic risk factors (Eslam, et al. J Hepatol 2020;73:202–209). Overall, 5-year and 10-year incidence of cirrhosis (defined by ICD-9/10) among non-cirrhotic patients was compared between groups using competing-risks Kaplan Meier methods and log-rank testing. Incidence of cirrhosis was further stratified by patient demographics and other relevant clinical variables, and comparisons were made between groups. Adjusted multivariate Cox proportional hazard models were utilized to determine significant predictors of cirrhosis.
Results: Our cohort included 969,253 patients with non-cirrhotic MAFLD, a majority of which were male (94.5%) and non-Hispanic white (70.2%) with mean age of 62.7 ± 12.2 years and mean BMI of 32.7 ± 12.2 kg/m2. 5-year incidence of cirrhosis was 2.42% (95% CI 2.39 – 2.45) and 10-year incidence of cirrhosis was 3.70% (95% CI 3.66 – 3.74) (Table 1). When stratified by race/ethnicity, 10-year incidence of cirrhosis was lowest among Asians (2.63%, 95% CI 2.37-2.88) and highest among Hispanics (4.60%, 95% CI 4.45-4.75). Compared to MAFLD patients with no substance use, those with high-risk alcohol use (7.00%, 95% CI 6.83-7.17) or active tobacco use (3.63%, 95% CI 3.63-5.37) had significantly higher 10-year incidence of cirrhosis. On adjusted multivariate analyses, risk of cirrhosis was significantly higher among Hispanics compared to non-Hispanic whites (HR 1.80, 95% CI 1.48-2.19, p<0.0001) (Table 2).
Conclusion: Among a national cohort of U.S. veterans with MAFLD, we identified racial/ethnic differences and other comorbidities which influenced the incidence of cirrhosis. More awareness of the underlying racial/ethnic disparities driving cirrhosis development, particularly for Hispanics, is important to guide future interventions to improve quality of care and clinical outcomes among patients with MAFLD.

Saturday
Society: AGA

Background: Hepatic encephalopathy (HE) is associated with increased mortality, falls, and frequent hospitalizations. Patient reported outcomes (PROs) are useful tools to assess health-related quality of life (HRQOL) measures such as impairment of sleep, cognition, or activity. PROs have also been shown to be reliable & valid tools to detect early signs of HE. Many clinicians initiate lactulose when patients present with poor PROs without cognitive testing, however data are limited regarding the efficacy of this strategy.
Methods: The Mi-Kristal trial is a single-center, randomized study to determine whether a 28-day regimen of Kristalose®, a crystalline lactulose therapy (20g BID) improves HRQOL in people with poor PROs. We enrolled patients with cirrhosis, portal hypertension, no prior HE, & Activity Impairment attributed to cirrhosis >3 (scale 0-10) because this score was highly predictive of overt HE in prior studies. Endpoints included the short form-8 (SF-8), animal naming test (ANT), falls, and a 4-point Likert scale rating sleep quality (very bad to very good).
Results: Fifty-six subjects were randomized, 52 subjects completed the protocol; 25 Kristalose and 27 no treatment. Median Baseline MELD-Na was 11 and ANT was 19 without differences between the groups at baseline. At Day 28 no significant difference was observed using the SF-8: subjects on Kristalose had an 8.1 point increase (95%CI 3.7-12.4) compared to 6.6 (95%CI 2.3-10.8) in control (p=0.6). Significant improvements were observed in subjects on Kristalose using the ANT which increased by 3.7 (95%CI 2.1-5.4) vs control - -0.2 (95%CI -1.7-1.4); 32% on Kristalose had a 5-point increase in ANT vs 11% of control. Falls were reported by 11% in control and 4% on Kristalose. At the end of the trial, 92% on Kristalose reported good sleep compared to 52% of control. Compared to control, Kristalose was associated with a significant 0.6 (95%CI0.3-1.0) point improvement in sleep quality and a significant 1.7 (95%CI0.3-3.1) point decrease in activity impairment.
Conclusion: Among patients with activity impairment at risk for HE, a 28-day crystalline lactulose regimen led to improved sleep, cognitive function & activity impairment. No significant difference in HRQOL was observed using the SF-8 possibly because the instrument is insensitive to change in this context or a longer treatment duration is required. A 6-month trial is planned. Our findings support the use of PROs to assess for benefit of HE-therapy and that early treatment improves select PROs.
Background
Endoscopic “palpation” of the liver is possible via endoscopic ultrasound (EUS). Regardless of body habitus, the EUS probe can be reproducibly positioned close to the liver surface. With a standard turn of the big wheel, the EUS probe indents the liver surface, and the level of indentation can be measured with sonographic calipers. Our hypothesis is that a fibrotic liver is harder to indent and the degree of indentation correlates with liver fibrosis severity. We aim to correlate EUS liver palpation with histology in patients with NAFLD and compare its predictive value for fibrosis staging to more conventional screening methods.
Methods
This was a cross sectional study of prospectively collected data. Consecutive patients at 3 hospitals between June 2021 and Nov 2022 underwent EUS liver palpation with subsequent liver biopsy. Index scores of Fibrosis-4 Index (FIB-4), AST to Platelet Ratio Index (APRI), NAFLD Fibrosis Score (NFS), and Agile 3+/4 per transient elastography (TE, i.e. Fibroscan) were calculated. Comparisons between EUS liver palpation and index scores/TE were performed using area under the curve (AUC) analysis.
Results
61 patients were evaluated. The mean age was 50. 64.5% were female. Average BMI was 41.2. EUS liver palpation significantly correlated with fibrosis stage on liver biopsy (p=0.0002) with lower indentation values at higher fibrosis stages [Figure 1A]. EUS palpation had AUC of 0.73, 0.80, and 0.98 for discriminating significant fibrosis (F0-1 vs F2-4), advanced fibrosis (F0-2 vs F3-4), and cirrhosis (F0-3 vs F4) respectively [Figure 1B]. EUS liver palpation was superior to APRI and NFS in predicting cirrhosis (p=0.004 and 0.038 respectively).. Indentation of ≤3.5mm yields sensitivity, specificity, positive predictive value, and negative predictive value of 64.7%, 100%, 100%, and 88% respectively for detecting advanced fibrosis.
35/61 (57%) patients had TE performed. In this sub-cohort, EUS palpation had higher AUC values than TE and Agile 3+/4 but this was not significantly different [Figure 2A]. Combination of palpation + Agile 3+/4 for advanced fibrosis and cirrhosis cutoffs were superior to TE alone (p=0.0018 and 0.017 respectively). Lastly, we discovered body mass index (BMI) may be a confounder for TE (Pearson coefficient r=0.70, p=0.0005) but not for EUS liver indentation (r=-0.30, p=0.062) [Figure 2B].
Conclusions
EUS liver palpation is a reliable, novel, and easy-to-use tool to screen for advanced fibrosis in patients with NAFLD, and may be superior to APRI and NFS in predicting cirrhosis. This can be useful in patients with obesity in which an elevated BMI may confound TE results, and may be a valuable minimally invasive tool for endohepatologists in liver fibrosis screening for the NAFLD population. Larger multicenter studies will help to better define the utility and reproducibility of EUS liver palpation.
Background: There is high prevalence of metabolic co-morbidities among U.S. veterans, and hence a high prevalence of metabolic dysfunction associated fatty liver disease (MAFLD). The long-term incidence of cirrhosis among veterans with MAFLD has not been well studied. We aimed to evaluate the overall risk of cirrhosis as well as disparities in cirrhosis incidence among a national cohort of U.S. Veterans with MAFLD.
Methods: We retrospectively evaluated the Veterans Affairs Corporate Data Warehouse from 2010-2021, which captures data on veterans receiving health care across the U.S. MAFLD was identified using established definitions: presence of hepatic steatosis (defined by hepatic steatosis index >36) plus >1 of the following: 1) body mass index >25 kg/m2 in non-Asians or >23 kg/m2 in Asians, 2) concurrent diabetes mellitus, or 3) >2 metabolic risk factors (Eslam, et al. J Hepatol 2020;73:202–209). Overall, 5-year and 10-year incidence of cirrhosis (defined by ICD-9/10) among non-cirrhotic patients was compared between groups using competing-risks Kaplan Meier methods and log-rank testing. Incidence of cirrhosis was further stratified by patient demographics and other relevant clinical variables, and comparisons were made between groups. Adjusted multivariate Cox proportional hazard models were utilized to determine significant predictors of cirrhosis.
Results: Our cohort included 969,253 patients with non-cirrhotic MAFLD, a majority of which were male (94.5%) and non-Hispanic white (70.2%) with mean age of 62.7 ± 12.2 years and mean BMI of 32.7 ± 12.2 kg/m2. 5-year incidence of cirrhosis was 2.42% (95% CI 2.39 – 2.45) and 10-year incidence of cirrhosis was 3.70% (95% CI 3.66 – 3.74) (Table 1). When stratified by race/ethnicity, 10-year incidence of cirrhosis was lowest among Asians (2.63%, 95% CI 2.37-2.88) and highest among Hispanics (4.60%, 95% CI 4.45-4.75). Compared to MAFLD patients with no substance use, those with high-risk alcohol use (7.00%, 95% CI 6.83-7.17) or active tobacco use (3.63%, 95% CI 3.63-5.37) had significantly higher 10-year incidence of cirrhosis. On adjusted multivariate analyses, risk of cirrhosis was significantly higher among Hispanics compared to non-Hispanic whites (HR 1.80, 95% CI 1.48-2.19, p<0.0001) (Table 2).
Conclusion: Among a national cohort of U.S. veterans with MAFLD, we identified racial/ethnic differences and other comorbidities which influenced the incidence of cirrhosis. More awareness of the underlying racial/ethnic disparities driving cirrhosis development, particularly for Hispanics, is important to guide future interventions to improve quality of care and clinical outcomes among patients with MAFLD.
Background: Hyperammonemia has been proven as a part of the development of hepatic encephalopathy (HE). However, the relationship between blood ammonia and the prediction of liver-related complications in patients with acute-on-chronic liver failure (ACLF) is less well defined. Therefore, this study aimed to evaluate the role of blood ammonia levels in predicting mortality, development, and progression of liver-related complications in patients with ACLF.

Methods: A prospective cohort of adult ACLF patients as per the APASL definition recruited from the ACLF Research Consortium (AARC, 31 centers) between April 2009 and December 2019; The total of 3,871 ACLF cases were enrolled, with the majority of them caused by alcohol (n = 3,279) and HBV infection (n=592). ACLF patients with the presence of arterial ammonia at baseline were enrolled for analysis. The primary outcome was death during follow-up. Liver-related complications were a composite endpoint of bacterial infection, overt HE, and ascites.

Results: A total of 701 ACLF patients were enrolled. Of these, 399 (56.9%) died during the mean follow-up of 31.3 ± 126.0 days. Mean CTP, MELD, and AARC score were 11.6 ± 1.6, 30.1 ± 7.8, and 9.5 ± 2.2, respectively. Within a month after admission, 170 (24.3%) and 282 (40.2%) patients developed or progressed to overt HE and liver-related complications, respectively. On multivariate cox-regression analysis, INR (HR=1.13, 95%CI: 1.05-1.22, p=0.001), serum creatinine (HR=1.01, 95%CI: 1.04-1.17, p=0.001), and arterial ammonia (HR=1.002, 95% CI: 1.001-1.002, p=0.001) were the independent predictors of death. ACLF caused by alcohol or hepatitis B did not show a significantly different level of arterial ammonia (p=0.41). Patients who developed or progressed from liver-related complications exhibited higher baseline ammonia levels than those who did not (146.3 ± 92.9 vs 122.1 ± 90.4 µmol/L, p<0.001). Subgroup analysis showed that ammonia level was associated with the development or progression of overt HE in 30 days but not ascites or bacterial infections. Ammonia level was significantly higher in patients who developed or progressed overt HE than in patients who did not (174.2 ± 114.2 vs 102.8 ± 67.7 µmol/L, p<0.001). On ROC analysis, arterial ammonia was a significant predictor for the development or progression of overt HE (AUROC = 0.72, 95%CI: 0.56-0.88, p=0.02). Arterial ammonia ≥ 161 µmol/L was an optimal cut-off for predicting the development or progression of overt HE with an AUROC of 0.68 (95% CI: 0.63-0.73, p=0.001), the positive predictive value of 66.7% and negative predictive value of 74.5%.

Conclusion: In ACLF patients, baseline arterial ammonia levels are associated with mortality, the development, and the progression of liver-related complications, particularly overt HE, but not ascites or bacterial infection.

Saturday
Society: AGA

Background: Hepatic encephalopathy (HE) is associated with increased mortality, falls, and frequent hospitalizations. Patient reported outcomes (PROs) are useful tools to assess health-related quality of life (HRQOL) measures such as impairment of sleep, cognition, or activity. PROs have also been shown to be reliable & valid tools to detect early signs of HE. Many clinicians initiate lactulose when patients present with poor PROs without cognitive testing, however data are limited regarding the efficacy of this strategy.
Methods: The Mi-Kristal trial is a single-center, randomized study to determine whether a 28-day regimen of Kristalose®, a crystalline lactulose therapy (20g BID) improves HRQOL in people with poor PROs. We enrolled patients with cirrhosis, portal hypertension, no prior HE, & Activity Impairment attributed to cirrhosis >3 (scale 0-10) because this score was highly predictive of overt HE in prior studies. Endpoints included the short form-8 (SF-8), animal naming test (ANT), falls, and a 4-point Likert scale rating sleep quality (very bad to very good).
Results: Fifty-six subjects were randomized, 52 subjects completed the protocol; 25 Kristalose and 27 no treatment. Median Baseline MELD-Na was 11 and ANT was 19 without differences between the groups at baseline. At Day 28 no significant difference was observed using the SF-8: subjects on Kristalose had an 8.1 point increase (95%CI 3.7-12.4) compared to 6.6 (95%CI 2.3-10.8) in control (p=0.6). Significant improvements were observed in subjects on Kristalose using the ANT which increased by 3.7 (95%CI 2.1-5.4) vs control - -0.2 (95%CI -1.7-1.4); 32% on Kristalose had a 5-point increase in ANT vs 11% of control. Falls were reported by 11% in control and 4% on Kristalose. At the end of the trial, 92% on Kristalose reported good sleep compared to 52% of control. Compared to control, Kristalose was associated with a significant 0.6 (95%CI0.3-1.0) point improvement in sleep quality and a significant 1.7 (95%CI0.3-3.1) point decrease in activity impairment.
Conclusion: Among patients with activity impairment at risk for HE, a 28-day crystalline lactulose regimen led to improved sleep, cognitive function & activity impairment. No significant difference in HRQOL was observed using the SF-8 possibly because the instrument is insensitive to change in this context or a longer treatment duration is required. A 6-month trial is planned. Our findings support the use of PROs to assess for benefit of HE-therapy and that early treatment improves select PROs.
Background
Endoscopic “palpation” of the liver is possible via endoscopic ultrasound (EUS). Regardless of body habitus, the EUS probe can be reproducibly positioned close to the liver surface. With a standard turn of the big wheel, the EUS probe indents the liver surface, and the level of indentation can be measured with sonographic calipers. Our hypothesis is that a fibrotic liver is harder to indent and the degree of indentation correlates with liver fibrosis severity. We aim to correlate EUS liver palpation with histology in patients with NAFLD and compare its predictive value for fibrosis staging to more conventional screening methods.
Methods
This was a cross sectional study of prospectively collected data. Consecutive patients at 3 hospitals between June 2021 and Nov 2022 underwent EUS liver palpation with subsequent liver biopsy. Index scores of Fibrosis-4 Index (FIB-4), AST to Platelet Ratio Index (APRI), NAFLD Fibrosis Score (NFS), and Agile 3+/4 per transient elastography (TE, i.e. Fibroscan) were calculated. Comparisons between EUS liver palpation and index scores/TE were performed using area under the curve (AUC) analysis.
Results
61 patients were evaluated. The mean age was 50. 64.5% were female. Average BMI was 41.2. EUS liver palpation significantly correlated with fibrosis stage on liver biopsy (p=0.0002) with lower indentation values at higher fibrosis stages [Figure 1A]. EUS palpation had AUC of 0.73, 0.80, and 0.98 for discriminating significant fibrosis (F0-1 vs F2-4), advanced fibrosis (F0-2 vs F3-4), and cirrhosis (F0-3 vs F4) respectively [Figure 1B]. EUS liver palpation was superior to APRI and NFS in predicting cirrhosis (p=0.004 and 0.038 respectively).. Indentation of ≤3.5mm yields sensitivity, specificity, positive predictive value, and negative predictive value of 64.7%, 100%, 100%, and 88% respectively for detecting advanced fibrosis.
35/61 (57%) patients had TE performed. In this sub-cohort, EUS palpation had higher AUC values than TE and Agile 3+/4 but this was not significantly different [Figure 2A]. Combination of palpation + Agile 3+/4 for advanced fibrosis and cirrhosis cutoffs were superior to TE alone (p=0.0018 and 0.017 respectively). Lastly, we discovered body mass index (BMI) may be a confounder for TE (Pearson coefficient r=0.70, p=0.0005) but not for EUS liver indentation (r=-0.30, p=0.062) [Figure 2B].
Conclusions
EUS liver palpation is a reliable, novel, and easy-to-use tool to screen for advanced fibrosis in patients with NAFLD, and may be superior to APRI and NFS in predicting cirrhosis. This can be useful in patients with obesity in which an elevated BMI may confound TE results, and may be a valuable minimally invasive tool for endohepatologists in liver fibrosis screening for the NAFLD population. Larger multicenter studies will help to better define the utility and reproducibility of EUS liver palpation.
Background: There is high prevalence of metabolic co-morbidities among U.S. veterans, and hence a high prevalence of metabolic dysfunction associated fatty liver disease (MAFLD). The long-term incidence of cirrhosis among veterans with MAFLD has not been well studied. We aimed to evaluate the overall risk of cirrhosis as well as disparities in cirrhosis incidence among a national cohort of U.S. Veterans with MAFLD.
Methods: We retrospectively evaluated the Veterans Affairs Corporate Data Warehouse from 2010-2021, which captures data on veterans receiving health care across the U.S. MAFLD was identified using established definitions: presence of hepatic steatosis (defined by hepatic steatosis index >36) plus >1 of the following: 1) body mass index >25 kg/m2 in non-Asians or >23 kg/m2 in Asians, 2) concurrent diabetes mellitus, or 3) >2 metabolic risk factors (Eslam, et al. J Hepatol 2020;73:202–209). Overall, 5-year and 10-year incidence of cirrhosis (defined by ICD-9/10) among non-cirrhotic patients was compared between groups using competing-risks Kaplan Meier methods and log-rank testing. Incidence of cirrhosis was further stratified by patient demographics and other relevant clinical variables, and comparisons were made between groups. Adjusted multivariate Cox proportional hazard models were utilized to determine significant predictors of cirrhosis.
Results: Our cohort included 969,253 patients with non-cirrhotic MAFLD, a majority of which were male (94.5%) and non-Hispanic white (70.2%) with mean age of 62.7 ± 12.2 years and mean BMI of 32.7 ± 12.2 kg/m2. 5-year incidence of cirrhosis was 2.42% (95% CI 2.39 – 2.45) and 10-year incidence of cirrhosis was 3.70% (95% CI 3.66 – 3.74) (Table 1). When stratified by race/ethnicity, 10-year incidence of cirrhosis was lowest among Asians (2.63%, 95% CI 2.37-2.88) and highest among Hispanics (4.60%, 95% CI 4.45-4.75). Compared to MAFLD patients with no substance use, those with high-risk alcohol use (7.00%, 95% CI 6.83-7.17) or active tobacco use (3.63%, 95% CI 3.63-5.37) had significantly higher 10-year incidence of cirrhosis. On adjusted multivariate analyses, risk of cirrhosis was significantly higher among Hispanics compared to non-Hispanic whites (HR 1.80, 95% CI 1.48-2.19, p<0.0001) (Table 2).
Conclusion: Among a national cohort of U.S. veterans with MAFLD, we identified racial/ethnic differences and other comorbidities which influenced the incidence of cirrhosis. More awareness of the underlying racial/ethnic disparities driving cirrhosis development, particularly for Hispanics, is important to guide future interventions to improve quality of care and clinical outcomes among patients with MAFLD.
Background: Hyperammonemia has been proven as a part of the development of hepatic encephalopathy (HE). However, the relationship between blood ammonia and the prediction of liver-related complications in patients with acute-on-chronic liver failure (ACLF) is less well defined. Therefore, this study aimed to evaluate the role of blood ammonia levels in predicting mortality, development, and progression of liver-related complications in patients with ACLF.

Methods: A prospective cohort of adult ACLF patients as per the APASL definition recruited from the ACLF Research Consortium (AARC, 31 centers) between April 2009 and December 2019; The total of 3,871 ACLF cases were enrolled, with the majority of them caused by alcohol (n = 3,279) and HBV infection (n=592). ACLF patients with the presence of arterial ammonia at baseline were enrolled for analysis. The primary outcome was death during follow-up. Liver-related complications were a composite endpoint of bacterial infection, overt HE, and ascites.

Results: A total of 701 ACLF patients were enrolled. Of these, 399 (56.9%) died during the mean follow-up of 31.3 ± 126.0 days. Mean CTP, MELD, and AARC score were 11.6 ± 1.6, 30.1 ± 7.8, and 9.5 ± 2.2, respectively. Within a month after admission, 170 (24.3%) and 282 (40.2%) patients developed or progressed to overt HE and liver-related complications, respectively. On multivariate cox-regression analysis, INR (HR=1.13, 95%CI: 1.05-1.22, p=0.001), serum creatinine (HR=1.01, 95%CI: 1.04-1.17, p=0.001), and arterial ammonia (HR=1.002, 95% CI: 1.001-1.002, p=0.001) were the independent predictors of death. ACLF caused by alcohol or hepatitis B did not show a significantly different level of arterial ammonia (p=0.41). Patients who developed or progressed from liver-related complications exhibited higher baseline ammonia levels than those who did not (146.3 ± 92.9 vs 122.1 ± 90.4 µmol/L, p<0.001). Subgroup analysis showed that ammonia level was associated with the development or progression of overt HE in 30 days but not ascites or bacterial infections. Ammonia level was significantly higher in patients who developed or progressed overt HE than in patients who did not (174.2 ± 114.2 vs 102.8 ± 67.7 µmol/L, p<0.001). On ROC analysis, arterial ammonia was a significant predictor for the development or progression of overt HE (AUROC = 0.72, 95%CI: 0.56-0.88, p=0.02). Arterial ammonia ≥ 161 µmol/L was an optimal cut-off for predicting the development or progression of overt HE with an AUROC of 0.68 (95% CI: 0.63-0.73, p=0.001), the positive predictive value of 66.7% and negative predictive value of 74.5%.

Conclusion: In ACLF patients, baseline arterial ammonia levels are associated with mortality, the development, and the progression of liver-related complications, particularly overt HE, but not ascites or bacterial infection.
Background: Autoimmune diseases can be associated with increased cardiovascular disease (CVD) risk. However, the magnitude of the risk of CVDs in patients with autoimmune Hepatitis (AIH) is not well established, and also risks have not been estimated at a population level. Hence, our study sought to assess whether AIH was associated with a risk for adverse cardiovascular events.
Methods: We conducted a population-based, multicenter, propensity score-matched cohort study with consecutive patients diagnosed with AIH using the TriNeTx research platform. The study group consisted of patients diagnosed with AIH. The control group consisted of patients who were never diagnosed with AIH or any other chronic liver disease (CLD). Patients who were diagnosed with CVDs prior to the index date were excluded from both cohorts. Patients in the AIH cohort were matched to the control group using 1:1 propensity score matching (PSM) to reduce confounding effects. The primary outcomes were defined as the first incidence of new-onset heart failure (HF), composite major adverse cardiovascular events (MACE) (unstable angina, myocardial infarction (MI), or cardiovascular interventions), MI, a composite of cerebrovascular disease (cerebral infarction, transient ischemic attack, ischemic or hemorrhagic stroke, carotid intervention). We performed secondary and sensitivity analyses to assess our findings' robustness. The incidence of adverse cardiovascular events was estimated using a Cox proportional hazards model with hazard ratios (HR) and 95% confidence intervals (CI).
Results: In the cohort, 11712 cases of AIH were matched to 8734379 controls. After PSM, both cohorts were well-matched (9075 patients). The mean duration of follow-up for the AIH and control cohorts were 5.9 ±1.3 and 6.7±1.1 years, respectively. Of the patients with AIH, 2118 (23.3%) had cirrhosis, and 6261 (69.1%) were on immunosuppressive treatment. During the follow-up, compared to controls, the AIH cohort had a significantly increased risk of MACE (217 vs 65; HR 4.36; 95% CI, 3.27-5.73), MI (94 vs 22; HR 5.86, 95% CI 3.66-9.39), HF (324 vs. 114; HR 3.61, 95% CI 2.91-4.48), and cerebrovascular diseases (314 vs 123; HR 3.32, 95% CI 2.69-4.11) (Table 1). In sensitivity analysis, by excluding the first-year outcomes, the risks of all the CVD outcomes persisted. In the secondary analysis, the risk of MACE (HR=2.64), HF (HR=2.38), and cerebrovascular disease (HR=4.05) remained significantly higher among AIH patients who had cirrhosis.
Conclusion: Patients with AIH have a substantially increased risk of adverse cardiovascular events. These findings warrant that targeted cardiovascular prevention measures to reduce cardiovascular events should become a routine part of the management of AIH. Further prospective studies are needed to confirm these findings.

Saturday
Society: AGA

Background: Hepatic encephalopathy (HE) is associated with increased mortality, falls, and frequent hospitalizations. Patient reported outcomes (PROs) are useful tools to assess health-related quality of life (HRQOL) measures such as impairment of sleep, cognition, or activity. PROs have also been shown to be reliable & valid tools to detect early signs of HE. Many clinicians initiate lactulose when patients present with poor PROs without cognitive testing, however data are limited regarding the efficacy of this strategy.
Methods: The Mi-Kristal trial is a single-center, randomized study to determine whether a 28-day regimen of Kristalose®, a crystalline lactulose therapy (20g BID) improves HRQOL in people with poor PROs. We enrolled patients with cirrhosis, portal hypertension, no prior HE, & Activity Impairment attributed to cirrhosis >3 (scale 0-10) because this score was highly predictive of overt HE in prior studies. Endpoints included the short form-8 (SF-8), animal naming test (ANT), falls, and a 4-point Likert scale rating sleep quality (very bad to very good).
Results: Fifty-six subjects were randomized, 52 subjects completed the protocol; 25 Kristalose and 27 no treatment. Median Baseline MELD-Na was 11 and ANT was 19 without differences between the groups at baseline. At Day 28 no significant difference was observed using the SF-8: subjects on Kristalose had an 8.1 point increase (95%CI 3.7-12.4) compared to 6.6 (95%CI 2.3-10.8) in control (p=0.6). Significant improvements were observed in subjects on Kristalose using the ANT which increased by 3.7 (95%CI 2.1-5.4) vs control - -0.2 (95%CI -1.7-1.4); 32% on Kristalose had a 5-point increase in ANT vs 11% of control. Falls were reported by 11% in control and 4% on Kristalose. At the end of the trial, 92% on Kristalose reported good sleep compared to 52% of control. Compared to control, Kristalose was associated with a significant 0.6 (95%CI0.3-1.0) point improvement in sleep quality and a significant 1.7 (95%CI0.3-3.1) point decrease in activity impairment.
Conclusion: Among patients with activity impairment at risk for HE, a 28-day crystalline lactulose regimen led to improved sleep, cognitive function & activity impairment. No significant difference in HRQOL was observed using the SF-8 possibly because the instrument is insensitive to change in this context or a longer treatment duration is required. A 6-month trial is planned. Our findings support the use of PROs to assess for benefit of HE-therapy and that early treatment improves select PROs.
Background
Endoscopic “palpation” of the liver is possible via endoscopic ultrasound (EUS). Regardless of body habitus, the EUS probe can be reproducibly positioned close to the liver surface. With a standard turn of the big wheel, the EUS probe indents the liver surface, and the level of indentation can be measured with sonographic calipers. Our hypothesis is that a fibrotic liver is harder to indent and the degree of indentation correlates with liver fibrosis severity. We aim to correlate EUS liver palpation with histology in patients with NAFLD and compare its predictive value for fibrosis staging to more conventional screening methods.
Methods
This was a cross sectional study of prospectively collected data. Consecutive patients at 3 hospitals between June 2021 and Nov 2022 underwent EUS liver palpation with subsequent liver biopsy. Index scores of Fibrosis-4 Index (FIB-4), AST to Platelet Ratio Index (APRI), NAFLD Fibrosis Score (NFS), and Agile 3+/4 per transient elastography (TE, i.e. Fibroscan) were calculated. Comparisons between EUS liver palpation and index scores/TE were performed using area under the curve (AUC) analysis.
Results
61 patients were evaluated. The mean age was 50. 64.5% were female. Average BMI was 41.2. EUS liver palpation significantly correlated with fibrosis stage on liver biopsy (p=0.0002) with lower indentation values at higher fibrosis stages [Figure 1A]. EUS palpation had AUC of 0.73, 0.80, and 0.98 for discriminating significant fibrosis (F0-1 vs F2-4), advanced fibrosis (F0-2 vs F3-4), and cirrhosis (F0-3 vs F4) respectively [Figure 1B]. EUS liver palpation was superior to APRI and NFS in predicting cirrhosis (p=0.004 and 0.038 respectively).. Indentation of ≤3.5mm yields sensitivity, specificity, positive predictive value, and negative predictive value of 64.7%, 100%, 100%, and 88% respectively for detecting advanced fibrosis.
35/61 (57%) patients had TE performed. In this sub-cohort, EUS palpation had higher AUC values than TE and Agile 3+/4 but this was not significantly different [Figure 2A]. Combination of palpation + Agile 3+/4 for advanced fibrosis and cirrhosis cutoffs were superior to TE alone (p=0.0018 and 0.017 respectively). Lastly, we discovered body mass index (BMI) may be a confounder for TE (Pearson coefficient r=0.70, p=0.0005) but not for EUS liver indentation (r=-0.30, p=0.062) [Figure 2B].
Conclusions
EUS liver palpation is a reliable, novel, and easy-to-use tool to screen for advanced fibrosis in patients with NAFLD, and may be superior to APRI and NFS in predicting cirrhosis. This can be useful in patients with obesity in which an elevated BMI may confound TE results, and may be a valuable minimally invasive tool for endohepatologists in liver fibrosis screening for the NAFLD population. Larger multicenter studies will help to better define the utility and reproducibility of EUS liver palpation.
Background: There is high prevalence of metabolic co-morbidities among U.S. veterans, and hence a high prevalence of metabolic dysfunction associated fatty liver disease (MAFLD). The long-term incidence of cirrhosis among veterans with MAFLD has not been well studied. We aimed to evaluate the overall risk of cirrhosis as well as disparities in cirrhosis incidence among a national cohort of U.S. Veterans with MAFLD.
Methods: We retrospectively evaluated the Veterans Affairs Corporate Data Warehouse from 2010-2021, which captures data on veterans receiving health care across the U.S. MAFLD was identified using established definitions: presence of hepatic steatosis (defined by hepatic steatosis index >36) plus >1 of the following: 1) body mass index >25 kg/m2 in non-Asians or >23 kg/m2 in Asians, 2) concurrent diabetes mellitus, or 3) >2 metabolic risk factors (Eslam, et al. J Hepatol 2020;73:202–209). Overall, 5-year and 10-year incidence of cirrhosis (defined by ICD-9/10) among non-cirrhotic patients was compared between groups using competing-risks Kaplan Meier methods and log-rank testing. Incidence of cirrhosis was further stratified by patient demographics and other relevant clinical variables, and comparisons were made between groups. Adjusted multivariate Cox proportional hazard models were utilized to determine significant predictors of cirrhosis.
Results: Our cohort included 969,253 patients with non-cirrhotic MAFLD, a majority of which were male (94.5%) and non-Hispanic white (70.2%) with mean age of 62.7 ± 12.2 years and mean BMI of 32.7 ± 12.2 kg/m2. 5-year incidence of cirrhosis was 2.42% (95% CI 2.39 – 2.45) and 10-year incidence of cirrhosis was 3.70% (95% CI 3.66 – 3.74) (Table 1). When stratified by race/ethnicity, 10-year incidence of cirrhosis was lowest among Asians (2.63%, 95% CI 2.37-2.88) and highest among Hispanics (4.60%, 95% CI 4.45-4.75). Compared to MAFLD patients with no substance use, those with high-risk alcohol use (7.00%, 95% CI 6.83-7.17) or active tobacco use (3.63%, 95% CI 3.63-5.37) had significantly higher 10-year incidence of cirrhosis. On adjusted multivariate analyses, risk of cirrhosis was significantly higher among Hispanics compared to non-Hispanic whites (HR 1.80, 95% CI 1.48-2.19, p<0.0001) (Table 2).
Conclusion: Among a national cohort of U.S. veterans with MAFLD, we identified racial/ethnic differences and other comorbidities which influenced the incidence of cirrhosis. More awareness of the underlying racial/ethnic disparities driving cirrhosis development, particularly for Hispanics, is important to guide future interventions to improve quality of care and clinical outcomes among patients with MAFLD.
Background: Hyperammonemia has been proven as a part of the development of hepatic encephalopathy (HE). However, the relationship between blood ammonia and the prediction of liver-related complications in patients with acute-on-chronic liver failure (ACLF) is less well defined. Therefore, this study aimed to evaluate the role of blood ammonia levels in predicting mortality, development, and progression of liver-related complications in patients with ACLF.

Methods: A prospective cohort of adult ACLF patients as per the APASL definition recruited from the ACLF Research Consortium (AARC, 31 centers) between April 2009 and December 2019; The total of 3,871 ACLF cases were enrolled, with the majority of them caused by alcohol (n = 3,279) and HBV infection (n=592). ACLF patients with the presence of arterial ammonia at baseline were enrolled for analysis. The primary outcome was death during follow-up. Liver-related complications were a composite endpoint of bacterial infection, overt HE, and ascites.

Results: A total of 701 ACLF patients were enrolled. Of these, 399 (56.9%) died during the mean follow-up of 31.3 ± 126.0 days. Mean CTP, MELD, and AARC score were 11.6 ± 1.6, 30.1 ± 7.8, and 9.5 ± 2.2, respectively. Within a month after admission, 170 (24.3%) and 282 (40.2%) patients developed or progressed to overt HE and liver-related complications, respectively. On multivariate cox-regression analysis, INR (HR=1.13, 95%CI: 1.05-1.22, p=0.001), serum creatinine (HR=1.01, 95%CI: 1.04-1.17, p=0.001), and arterial ammonia (HR=1.002, 95% CI: 1.001-1.002, p=0.001) were the independent predictors of death. ACLF caused by alcohol or hepatitis B did not show a significantly different level of arterial ammonia (p=0.41). Patients who developed or progressed from liver-related complications exhibited higher baseline ammonia levels than those who did not (146.3 ± 92.9 vs 122.1 ± 90.4 µmol/L, p<0.001). Subgroup analysis showed that ammonia level was associated with the development or progression of overt HE in 30 days but not ascites or bacterial infections. Ammonia level was significantly higher in patients who developed or progressed overt HE than in patients who did not (174.2 ± 114.2 vs 102.8 ± 67.7 µmol/L, p<0.001). On ROC analysis, arterial ammonia was a significant predictor for the development or progression of overt HE (AUROC = 0.72, 95%CI: 0.56-0.88, p=0.02). Arterial ammonia ≥ 161 µmol/L was an optimal cut-off for predicting the development or progression of overt HE with an AUROC of 0.68 (95% CI: 0.63-0.73, p=0.001), the positive predictive value of 66.7% and negative predictive value of 74.5%.

Conclusion: In ACLF patients, baseline arterial ammonia levels are associated with mortality, the development, and the progression of liver-related complications, particularly overt HE, but not ascites or bacterial infection.
Background: Autoimmune diseases can be associated with increased cardiovascular disease (CVD) risk. However, the magnitude of the risk of CVDs in patients with autoimmune Hepatitis (AIH) is not well established, and also risks have not been estimated at a population level. Hence, our study sought to assess whether AIH was associated with a risk for adverse cardiovascular events.
Methods: We conducted a population-based, multicenter, propensity score-matched cohort study with consecutive patients diagnosed with AIH using the TriNeTx research platform. The study group consisted of patients diagnosed with AIH. The control group consisted of patients who were never diagnosed with AIH or any other chronic liver disease (CLD). Patients who were diagnosed with CVDs prior to the index date were excluded from both cohorts. Patients in the AIH cohort were matched to the control group using 1:1 propensity score matching (PSM) to reduce confounding effects. The primary outcomes were defined as the first incidence of new-onset heart failure (HF), composite major adverse cardiovascular events (MACE) (unstable angina, myocardial infarction (MI), or cardiovascular interventions), MI, a composite of cerebrovascular disease (cerebral infarction, transient ischemic attack, ischemic or hemorrhagic stroke, carotid intervention). We performed secondary and sensitivity analyses to assess our findings' robustness. The incidence of adverse cardiovascular events was estimated using a Cox proportional hazards model with hazard ratios (HR) and 95% confidence intervals (CI).
Results: In the cohort, 11712 cases of AIH were matched to 8734379 controls. After PSM, both cohorts were well-matched (9075 patients). The mean duration of follow-up for the AIH and control cohorts were 5.9 ±1.3 and 6.7±1.1 years, respectively. Of the patients with AIH, 2118 (23.3%) had cirrhosis, and 6261 (69.1%) were on immunosuppressive treatment. During the follow-up, compared to controls, the AIH cohort had a significantly increased risk of MACE (217 vs 65; HR 4.36; 95% CI, 3.27-5.73), MI (94 vs 22; HR 5.86, 95% CI 3.66-9.39), HF (324 vs. 114; HR 3.61, 95% CI 2.91-4.48), and cerebrovascular diseases (314 vs 123; HR 3.32, 95% CI 2.69-4.11) (Table 1). In sensitivity analysis, by excluding the first-year outcomes, the risks of all the CVD outcomes persisted. In the secondary analysis, the risk of MACE (HR=2.64), HF (HR=2.38), and cerebrovascular disease (HR=4.05) remained significantly higher among AIH patients who had cirrhosis.
Conclusion: Patients with AIH have a substantially increased risk of adverse cardiovascular events. These findings warrant that targeted cardiovascular prevention measures to reduce cardiovascular events should become a routine part of the management of AIH. Further prospective studies are needed to confirm these findings.
Background: There is no therapy has been shown to reduce the risk of serious adverse outcomes in patients with nonalcoholic fatty liver disease (NAFLD). Hence, novel treatment strategies are needed. Here, we aimed to explore the macrovascular outcomes as well as mortality for patients with NAFLD and type 2 diabetes mellitus (T2DM) taking Glucagon-like Peptide-1 Receptor Agonists (GLP-1RA) compared to other glucose-lowering drugs.
Methods: We conducted a population-based, multicenter cohort study with consecutive patients diagnosed with NAFLD and T2DM using the TriNeTx. Cohort entry was defined as the date of the first-ever prescription for one of the drugs of interest (GLP-1 RAs) or SGLT-2 inhibitors or metformin or other second/third-line drugs during the study period. We used a lag of 6 months for all exposures to minimize protopathic bias. We performed a 1:1 propensity score matching (PSM) to reduce confounding effects. The primary outcomes were defined as the first incidence of new-onset heart failure (HF), composite major adverse cardiovascular events (MACE), and a composite of cerebrovascular disease, and the secondary outcome was mortality. We conducted a secondary analysis and sensitivity analysis to assess the robustness of our findings. The outcomes were estimated using a Cox proportional hazards model with hazard ratios (HR) and 95% confidence intervals (CI).
Results: In this cohort, 53249 patients received GLP-1A treatment, and 39795 patients received SGLT-2 inhibitor treatment and were included in the control. For sensitivity analysis, 103667 were in the Metformin, and 2638687 were in second/third line anti-diabetic treatment. The GLP-1RA group was non-inferior to the SGLT2 group in terms of CV outcomes: the incidence of MACE (HR, 1.06), HF (HR, 10.9), cerebrovascular diseases (HR, 0.99) was similar compared with the SGLT2 group (Table 1). Moreover, the mortality rates between the GLP-1RA were non-inferior to the SGLT2 group (HR, 1.06). When compared to patients taking metformin, a significantly lower risk of macrovascular and cerebrovascular diseases and HF was observed. Strikingly, mortality was significantly reduced in the GLP1R-A group compared to the metformin group (HR 0.70). When compared to patients taking second/third-line glucose-lowering drugs also, a significantly lower risk of macrovascular diseases, HF, and mortality was observed (HRs 0.90). Sensitivity analysis showed a similar magnitude to the one generated in the primary and secondary analyses.
CONCLUSION: Patients who started GLP1-RA treatment showed a significantly lower incidence of macrovascular diseases and all-cause mortality rates, and GLP1-RA was not inferior to SGLT2 inhibitors. Both GLP1-RA and SGLT2 inhibitors seem to be safe and efficacious drugs to lower the risk of CV outcomes in patients with NAFLD and T2DM.
<b>Table 1. Cardiovascular outcomes between the Users of GLP-1RA vs. SGLT2 in patients with NAFLD and type 2 diabetes </b>

Table 1. Cardiovascular outcomes between the Users of GLP-1RA vs. SGLT2 in patients with NAFLD and type 2 diabetes


09:00am - 10:30am EDT - May 6, 2023 | Room: W196 (McCormick Place)
James Lewis, Moderator; Sara Horst, Moderator
Society: AGA
Type: Research Forum
Society: AGA


Saturday
Society: AGA

BACKGROUND: Prevention of postoperative recurrence (POR) in Crohn’s disease (CD) after ileo-colonic (IC) resection is still a highly debated topic. Prophylactic immunosuppression after surgery is currently recommended in presence of at least one clinical risk factor (RF). Due to drug-related adverse events and the relative high cost of biologics, we aimed to determine whether prevention of POR can be postponed and guided by endoscopy in CD patients with only one RF.
METHODS: A multicentre retrospective study was conducted in 12 Italian centres. CD patients with only one RF for POR, including previous intestinal resection, extensive small intestine resection (>50 cm), fistulising phenotype, history of perianal disease, or active smoking were considered. Patients who performed a colonoscopy between 6 to 12 months after curative IC resection were included. Two groups were formed based on whether immunosuppressive therapy was started immediately after surgery (prophylaxis group) or guided by endoscopy (observation group). Primary endpoints were the rates of any endoscopic recurrence (Rutgeerts ≥i2a) and severe endoscopic recurrence (i4) within 12 months after surgery. Secondary outcomes were clinical recurrence (HBI≥5) rates at 6, 12 and 24 months after surgery.
RESULTS: A total of 195 patients were enrolled. Out of all, 61 (31.3%) received immunoprophylaxis at a median time of 32 days [IQR 26-55] after surgery (n=14 infliximab, n=37 adalimumab, n=7 azathioprine, n=3 ustekinumab). Baseline patient characteristics are detailed in Table 1. Particularly, risk factors for POR were homogeneously distributed between the 2 groups. Colonoscopy was performed after a median time of 8 months [IQR 6-11]. No differences between immunoprophylaxis and endoscopy-driven approach was found regarding any endoscopic recurrence (36.1% in prophylaxis group vs 45.5% in observation group, p=0.10) and severe endoscopic recurrence (9.8% in prophylaxis group vs 15.7% in observation group, p=0.15). In 32 patients with a second colonoscopy at a median time of 30.5 months [IQR 22-43.75] after surgery, any recurrence and severe recurrence rates were also similar (p=0.55 and p=0.43, respectively).
Early clinical recurrence at 6 months was reported in 23.4% of patients on immunoprophylaxis vs 31.5% who were not (p=0.43). Clinical recurrence rates between prophylaxis and observation group were also similar at 12 months (17.9% vs 34.8%, respectively, p=0.09) and at 24 months (17.9% vs 24.1%, respectively, p=0.63).
CONCLUSION: In CD patients with only one RF for POR, immediate immunoprophylaxis after curative IC resection does not decrease the rate of early clinical and endoscopic recurrence. Prospective and larger studies are needed to confirm our results.

Saturday
Society: AGA

BACKGROUND: Prevention of postoperative recurrence (POR) in Crohn’s disease (CD) after ileo-colonic (IC) resection is still a highly debated topic. Prophylactic immunosuppression after surgery is currently recommended in presence of at least one clinical risk factor (RF). Due to drug-related adverse events and the relative high cost of biologics, we aimed to determine whether prevention of POR can be postponed and guided by endoscopy in CD patients with only one RF.
METHODS: A multicentre retrospective study was conducted in 12 Italian centres. CD patients with only one RF for POR, including previous intestinal resection, extensive small intestine resection (>50 cm), fistulising phenotype, history of perianal disease, or active smoking were considered. Patients who performed a colonoscopy between 6 to 12 months after curative IC resection were included. Two groups were formed based on whether immunosuppressive therapy was started immediately after surgery (prophylaxis group) or guided by endoscopy (observation group). Primary endpoints were the rates of any endoscopic recurrence (Rutgeerts ≥i2a) and severe endoscopic recurrence (i4) within 12 months after surgery. Secondary outcomes were clinical recurrence (HBI≥5) rates at 6, 12 and 24 months after surgery.
RESULTS: A total of 195 patients were enrolled. Out of all, 61 (31.3%) received immunoprophylaxis at a median time of 32 days [IQR 26-55] after surgery (n=14 infliximab, n=37 adalimumab, n=7 azathioprine, n=3 ustekinumab). Baseline patient characteristics are detailed in Table 1. Particularly, risk factors for POR were homogeneously distributed between the 2 groups. Colonoscopy was performed after a median time of 8 months [IQR 6-11]. No differences between immunoprophylaxis and endoscopy-driven approach was found regarding any endoscopic recurrence (36.1% in prophylaxis group vs 45.5% in observation group, p=0.10) and severe endoscopic recurrence (9.8% in prophylaxis group vs 15.7% in observation group, p=0.15). In 32 patients with a second colonoscopy at a median time of 30.5 months [IQR 22-43.75] after surgery, any recurrence and severe recurrence rates were also similar (p=0.55 and p=0.43, respectively).
Early clinical recurrence at 6 months was reported in 23.4% of patients on immunoprophylaxis vs 31.5% who were not (p=0.43). Clinical recurrence rates between prophylaxis and observation group were also similar at 12 months (17.9% vs 34.8%, respectively, p=0.09) and at 24 months (17.9% vs 24.1%, respectively, p=0.63).
CONCLUSION: In CD patients with only one RF for POR, immediate immunoprophylaxis after curative IC resection does not decrease the rate of early clinical and endoscopic recurrence. Prospective and larger studies are needed to confirm our results.
Background
Early treatment of Crohn’s disease (CD) often involves biologics such as anti-tumor necrosis factor (anti-TNF) agents. Ileocecal resection (ICR), while a therapeutic option in early CD, is generally reserved for complicated CD or when medical treatment fails. We aimed to compare long-term outcomes of ICR and anti-TNF therapy as index treatment for ileocecal CD, initiated within one year of diagnosis, in the Danish nationwide cohort.

Methods
Using cross-linked nationwide registers, we identified all individuals who lived in Denmark and were diagnosed with ileal CD between 2003 and 2018. We included individuals who underwent ICR or received anti-TNF drugs as index treatment for ileocecal CD within one year of diagnosis. We excluded patients who did not have pathology information confirming disease in the ileocecal region. The primary outcome was a composite of CD-related hospitalization, systemic corticosteroid exposure, CD-related surgery, and perianal CD diagnosis. We conducted Cox proportional hazards regression analyses to compare outcomes in the two groups after adjusting for potential confounders. We also determined the proportion of individuals initiated on immunomodulator (IMM), anti-TNF, or no therapy at 5 years after ICR.

Results
Of the 16,443 individuals diagnosed with ileocecal CD between 2003 and 2018, 581 (3.5%) and 698 (4.2%) individuals with confirmed disease in the ileocecal region underwent ICR and received anti-TNF as the index treatment, respectively. The composite outcome occurred in 273 individuals (IR 110.3/100,0 person years (PY)) in the ICR group and in 318 individuals (IR 201.9/100,0 PY) in the anti-TNF group. The risk of the composite outcome was 33% lower in the ICR group compared to the anti-TNF group (aHR 0.67; 95% CI 0.54, 0.83), after adjusting for demographic and clinical variables. On analysis of individual outcomes, ICR was associated with reduced risk of systemic corticosteroid exposure and CD-related surgery, but not CD-related hospitalization or perianal CD diagnosis. Of individuals who underwent ICR, the proportion that was initiated on IMM, anti-TNF treatment or no treatment at 5 years of follow up was 47.5%, 17.1%, and 50.3%, respectively.

Conclusion
These data support the role of ICR as an index treatment for ileocecal CD and challenge the current paradigm of reserving surgery for complicated CD refractory or intolerant to medications. Further studies will help identify characteristics of individuals who needed no treatment after ICR.

Saturday
Society: AGA

BACKGROUND: Prevention of postoperative recurrence (POR) in Crohn’s disease (CD) after ileo-colonic (IC) resection is still a highly debated topic. Prophylactic immunosuppression after surgery is currently recommended in presence of at least one clinical risk factor (RF). Due to drug-related adverse events and the relative high cost of biologics, we aimed to determine whether prevention of POR can be postponed and guided by endoscopy in CD patients with only one RF.
METHODS: A multicentre retrospective study was conducted in 12 Italian centres. CD patients with only one RF for POR, including previous intestinal resection, extensive small intestine resection (>50 cm), fistulising phenotype, history of perianal disease, or active smoking were considered. Patients who performed a colonoscopy between 6 to 12 months after curative IC resection were included. Two groups were formed based on whether immunosuppressive therapy was started immediately after surgery (prophylaxis group) or guided by endoscopy (observation group). Primary endpoints were the rates of any endoscopic recurrence (Rutgeerts ≥i2a) and severe endoscopic recurrence (i4) within 12 months after surgery. Secondary outcomes were clinical recurrence (HBI≥5) rates at 6, 12 and 24 months after surgery.
RESULTS: A total of 195 patients were enrolled. Out of all, 61 (31.3%) received immunoprophylaxis at a median time of 32 days [IQR 26-55] after surgery (n=14 infliximab, n=37 adalimumab, n=7 azathioprine, n=3 ustekinumab). Baseline patient characteristics are detailed in Table 1. Particularly, risk factors for POR were homogeneously distributed between the 2 groups. Colonoscopy was performed after a median time of 8 months [IQR 6-11]. No differences between immunoprophylaxis and endoscopy-driven approach was found regarding any endoscopic recurrence (36.1% in prophylaxis group vs 45.5% in observation group, p=0.10) and severe endoscopic recurrence (9.8% in prophylaxis group vs 15.7% in observation group, p=0.15). In 32 patients with a second colonoscopy at a median time of 30.5 months [IQR 22-43.75] after surgery, any recurrence and severe recurrence rates were also similar (p=0.55 and p=0.43, respectively).
Early clinical recurrence at 6 months was reported in 23.4% of patients on immunoprophylaxis vs 31.5% who were not (p=0.43). Clinical recurrence rates between prophylaxis and observation group were also similar at 12 months (17.9% vs 34.8%, respectively, p=0.09) and at 24 months (17.9% vs 24.1%, respectively, p=0.63).
CONCLUSION: In CD patients with only one RF for POR, immediate immunoprophylaxis after curative IC resection does not decrease the rate of early clinical and endoscopic recurrence. Prospective and larger studies are needed to confirm our results.
Background
Early treatment of Crohn’s disease (CD) often involves biologics such as anti-tumor necrosis factor (anti-TNF) agents. Ileocecal resection (ICR), while a therapeutic option in early CD, is generally reserved for complicated CD or when medical treatment fails. We aimed to compare long-term outcomes of ICR and anti-TNF therapy as index treatment for ileocecal CD, initiated within one year of diagnosis, in the Danish nationwide cohort.

Methods
Using cross-linked nationwide registers, we identified all individuals who lived in Denmark and were diagnosed with ileal CD between 2003 and 2018. We included individuals who underwent ICR or received anti-TNF drugs as index treatment for ileocecal CD within one year of diagnosis. We excluded patients who did not have pathology information confirming disease in the ileocecal region. The primary outcome was a composite of CD-related hospitalization, systemic corticosteroid exposure, CD-related surgery, and perianal CD diagnosis. We conducted Cox proportional hazards regression analyses to compare outcomes in the two groups after adjusting for potential confounders. We also determined the proportion of individuals initiated on immunomodulator (IMM), anti-TNF, or no therapy at 5 years after ICR.

Results
Of the 16,443 individuals diagnosed with ileocecal CD between 2003 and 2018, 581 (3.5%) and 698 (4.2%) individuals with confirmed disease in the ileocecal region underwent ICR and received anti-TNF as the index treatment, respectively. The composite outcome occurred in 273 individuals (IR 110.3/100,0 person years (PY)) in the ICR group and in 318 individuals (IR 201.9/100,0 PY) in the anti-TNF group. The risk of the composite outcome was 33% lower in the ICR group compared to the anti-TNF group (aHR 0.67; 95% CI 0.54, 0.83), after adjusting for demographic and clinical variables. On analysis of individual outcomes, ICR was associated with reduced risk of systemic corticosteroid exposure and CD-related surgery, but not CD-related hospitalization or perianal CD diagnosis. Of individuals who underwent ICR, the proportion that was initiated on IMM, anti-TNF treatment or no treatment at 5 years of follow up was 47.5%, 17.1%, and 50.3%, respectively.

Conclusion
These data support the role of ICR as an index treatment for ileocecal CD and challenge the current paradigm of reserving surgery for complicated CD refractory or intolerant to medications. Further studies will help identify characteristics of individuals who needed no treatment after ICR.
Background
We aimed to compare the effectiveness of tofacitinib and ustekinumab in patients with ulcerative colitis (UC) previously exposed to at least one anti-TNF agent.
Methods
In this multicenter study, we retrospectively included consecutive UC adult patients previously exposed to at least one anti-TNF agent, with partial Mayo score (pMS) > 2, having who started tofacitinib or ustekinumab between January 2019 and June 2022.
The primary endpoint was steroid-free clinical remission (pMS ≤ 2) (CFREM) at week 16 (W16).
Secondary endpoints were endoscopic remission (CFREM + Mayo endoscopic score (MES) ≤ 1), and histological remission (CFREM + MES ≤ 1 + Nancy index ≤ 1).
Comparisons were performed using propensity score analyses adjusted on potential confounders.
Results
Overall, 289 patients were included (tofacitinib = 124 patients, ustekinumab = 165 patients). The groups were comparable (tofacitinib vs vedolizumab) for male gender (50.8% vs 43.3%), mean age (40.7 vs 42.9 years), median UC duration (8.6 vs 9.3 years), concomitant use of 5-ASA (13.7% vs 9.7%), steroids (25.0% vs 29.7%), immunosuppressants (7.3% vs 5.5%), and ≥ 2 prior biologics (85.5% vs 82.4%). Tofacitinib group had more pancolitis (55.6% vs 42.4%, p = 0.026) and UC with pMS > 6 (64.5% vs 50.3%, p = 0.016). In our study, 42.1 % of the patients treated with tofacitinib continued using a dose of 10 mgx2/day until W16 while 47.3% of the patients on ustekinumab required dose escalation to 90 mg/4 weeks before W16.
After propensity score analysis, the rate of CFREM at W16 was 37.8% and 35.6% in the tofacitinib and ustekinumab arms, respectively arm (p=0.75). CFREM at W16 was achieved in 43.3% vs 57.1% (p = 0.48) after failure of one biologic, 20.7% vs 37.9% (p=0.16) two biologics and 46.7% vs 23.2% (p=0.047) if ≥ 3 biologics, in tofacitinib and vedolizumab arms, respectively. After primary failure to at least one biologic, the rate of CFREM at W16 was 46.3% on tofacitinib vs 25.9% on ustekinumab (p = 0.13). CFREM at W16 was similar with tofacitinib and ustekinumab in case of more severe UC such as pMS ≥ 6 (40.6% vs 41.5%) and CRP > 30 (27.2% vs 33.0%).
No predictor of tofacitinib effectiveness has been identified. Factors associated with no CFREM at W16 on ustekinumab were male gender (p=0.035), ≥ 3 prior biologics (p=0.013), prior use of tofacitinib (p=0.03), primary failure to at least one biologic (p=0.013).
After propensity score analysis, endoscopic remission was achieved in 17.0% vs 11.7% (p =0.47) and histological remission in 4.4% vs 7.8% (p=0.32) of the patients treated with tofacitinib and ustekinumab, respectively.
Conclusion
Tofacitinib and ustekinumab have similar effectiveness in UC after anti-TNF failure.
However, the efficacy of ustekinumab could be more impacted by prior therapeutic failures.

Saturday
Society: AGA

BACKGROUND: Prevention of postoperative recurrence (POR) in Crohn’s disease (CD) after ileo-colonic (IC) resection is still a highly debated topic. Prophylactic immunosuppression after surgery is currently recommended in presence of at least one clinical risk factor (RF). Due to drug-related adverse events and the relative high cost of biologics, we aimed to determine whether prevention of POR can be postponed and guided by endoscopy in CD patients with only one RF.
METHODS: A multicentre retrospective study was conducted in 12 Italian centres. CD patients with only one RF for POR, including previous intestinal resection, extensive small intestine resection (>50 cm), fistulising phenotype, history of perianal disease, or active smoking were considered. Patients who performed a colonoscopy between 6 to 12 months after curative IC resection were included. Two groups were formed based on whether immunosuppressive therapy was started immediately after surgery (prophylaxis group) or guided by endoscopy (observation group). Primary endpoints were the rates of any endoscopic recurrence (Rutgeerts ≥i2a) and severe endoscopic recurrence (i4) within 12 months after surgery. Secondary outcomes were clinical recurrence (HBI≥5) rates at 6, 12 and 24 months after surgery.
RESULTS: A total of 195 patients were enrolled. Out of all, 61 (31.3%) received immunoprophylaxis at a median time of 32 days [IQR 26-55] after surgery (n=14 infliximab, n=37 adalimumab, n=7 azathioprine, n=3 ustekinumab). Baseline patient characteristics are detailed in Table 1. Particularly, risk factors for POR were homogeneously distributed between the 2 groups. Colonoscopy was performed after a median time of 8 months [IQR 6-11]. No differences between immunoprophylaxis and endoscopy-driven approach was found regarding any endoscopic recurrence (36.1% in prophylaxis group vs 45.5% in observation group, p=0.10) and severe endoscopic recurrence (9.8% in prophylaxis group vs 15.7% in observation group, p=0.15). In 32 patients with a second colonoscopy at a median time of 30.5 months [IQR 22-43.75] after surgery, any recurrence and severe recurrence rates were also similar (p=0.55 and p=0.43, respectively).
Early clinical recurrence at 6 months was reported in 23.4% of patients on immunoprophylaxis vs 31.5% who were not (p=0.43). Clinical recurrence rates between prophylaxis and observation group were also similar at 12 months (17.9% vs 34.8%, respectively, p=0.09) and at 24 months (17.9% vs 24.1%, respectively, p=0.63).
CONCLUSION: In CD patients with only one RF for POR, immediate immunoprophylaxis after curative IC resection does not decrease the rate of early clinical and endoscopic recurrence. Prospective and larger studies are needed to confirm our results.
Background
Early treatment of Crohn’s disease (CD) often involves biologics such as anti-tumor necrosis factor (anti-TNF) agents. Ileocecal resection (ICR), while a therapeutic option in early CD, is generally reserved for complicated CD or when medical treatment fails. We aimed to compare long-term outcomes of ICR and anti-TNF therapy as index treatment for ileocecal CD, initiated within one year of diagnosis, in the Danish nationwide cohort.

Methods
Using cross-linked nationwide registers, we identified all individuals who lived in Denmark and were diagnosed with ileal CD between 2003 and 2018. We included individuals who underwent ICR or received anti-TNF drugs as index treatment for ileocecal CD within one year of diagnosis. We excluded patients who did not have pathology information confirming disease in the ileocecal region. The primary outcome was a composite of CD-related hospitalization, systemic corticosteroid exposure, CD-related surgery, and perianal CD diagnosis. We conducted Cox proportional hazards regression analyses to compare outcomes in the two groups after adjusting for potential confounders. We also determined the proportion of individuals initiated on immunomodulator (IMM), anti-TNF, or no therapy at 5 years after ICR.

Results
Of the 16,443 individuals diagnosed with ileocecal CD between 2003 and 2018, 581 (3.5%) and 698 (4.2%) individuals with confirmed disease in the ileocecal region underwent ICR and received anti-TNF as the index treatment, respectively. The composite outcome occurred in 273 individuals (IR 110.3/100,0 person years (PY)) in the ICR group and in 318 individuals (IR 201.9/100,0 PY) in the anti-TNF group. The risk of the composite outcome was 33% lower in the ICR group compared to the anti-TNF group (aHR 0.67; 95% CI 0.54, 0.83), after adjusting for demographic and clinical variables. On analysis of individual outcomes, ICR was associated with reduced risk of systemic corticosteroid exposure and CD-related surgery, but not CD-related hospitalization or perianal CD diagnosis. Of individuals who underwent ICR, the proportion that was initiated on IMM, anti-TNF treatment or no treatment at 5 years of follow up was 47.5%, 17.1%, and 50.3%, respectively.

Conclusion
These data support the role of ICR as an index treatment for ileocecal CD and challenge the current paradigm of reserving surgery for complicated CD refractory or intolerant to medications. Further studies will help identify characteristics of individuals who needed no treatment after ICR.
Background
We aimed to compare the effectiveness of tofacitinib and ustekinumab in patients with ulcerative colitis (UC) previously exposed to at least one anti-TNF agent.
Methods
In this multicenter study, we retrospectively included consecutive UC adult patients previously exposed to at least one anti-TNF agent, with partial Mayo score (pMS) > 2, having who started tofacitinib or ustekinumab between January 2019 and June 2022.
The primary endpoint was steroid-free clinical remission (pMS ≤ 2) (CFREM) at week 16 (W16).
Secondary endpoints were endoscopic remission (CFREM + Mayo endoscopic score (MES) ≤ 1), and histological remission (CFREM + MES ≤ 1 + Nancy index ≤ 1).
Comparisons were performed using propensity score analyses adjusted on potential confounders.
Results
Overall, 289 patients were included (tofacitinib = 124 patients, ustekinumab = 165 patients). The groups were comparable (tofacitinib vs vedolizumab) for male gender (50.8% vs 43.3%), mean age (40.7 vs 42.9 years), median UC duration (8.6 vs 9.3 years), concomitant use of 5-ASA (13.7% vs 9.7%), steroids (25.0% vs 29.7%), immunosuppressants (7.3% vs 5.5%), and ≥ 2 prior biologics (85.5% vs 82.4%). Tofacitinib group had more pancolitis (55.6% vs 42.4%, p = 0.026) and UC with pMS > 6 (64.5% vs 50.3%, p = 0.016). In our study, 42.1 % of the patients treated with tofacitinib continued using a dose of 10 mgx2/day until W16 while 47.3% of the patients on ustekinumab required dose escalation to 90 mg/4 weeks before W16.
After propensity score analysis, the rate of CFREM at W16 was 37.8% and 35.6% in the tofacitinib and ustekinumab arms, respectively arm (p=0.75). CFREM at W16 was achieved in 43.3% vs 57.1% (p = 0.48) after failure of one biologic, 20.7% vs 37.9% (p=0.16) two biologics and 46.7% vs 23.2% (p=0.047) if ≥ 3 biologics, in tofacitinib and vedolizumab arms, respectively. After primary failure to at least one biologic, the rate of CFREM at W16 was 46.3% on tofacitinib vs 25.9% on ustekinumab (p = 0.13). CFREM at W16 was similar with tofacitinib and ustekinumab in case of more severe UC such as pMS ≥ 6 (40.6% vs 41.5%) and CRP > 30 (27.2% vs 33.0%).
No predictor of tofacitinib effectiveness has been identified. Factors associated with no CFREM at W16 on ustekinumab were male gender (p=0.035), ≥ 3 prior biologics (p=0.013), prior use of tofacitinib (p=0.03), primary failure to at least one biologic (p=0.013).
After propensity score analysis, endoscopic remission was achieved in 17.0% vs 11.7% (p =0.47) and histological remission in 4.4% vs 7.8% (p=0.32) of the patients treated with tofacitinib and ustekinumab, respectively.
Conclusion
Tofacitinib and ustekinumab have similar effectiveness in UC after anti-TNF failure.
However, the efficacy of ustekinumab could be more impacted by prior therapeutic failures.
Introduction
Approximately 15% of patients with ulcerative colitis (UC) will develop Crohn’s disease of the pouch (CDP) after total proctocolectomy with ileal pouch anal anastomosis (IPAA). Data to support the use of biologics or small molecules in patients with CDP is limited and little is known about real-world treatment patterns in these patients. The aim of this study was to evaluate patterns of biologic and small molecule use and assess remission rates in patients with CDP.

Methods
This was a prospective, multicenter study of patients with CDP on therapy. Clinical assessments were performed at baseline and 3, 6, and 12 months after enrollment. The diagnosis of CDP was made by the enrolling physician and was based on the following criteria: inflammation of the pre-pouch ileum, strictures involving the pouch or pre-pouch ileum, and/or fistulae involving the pouch or pre-pouch ileum. Remission was defined as a clinical modified Pouchitis Disease Activity Index score <2. Fisher’s exact test was used to compare categorical variables and the Kruskal-Wallis test was used to compare continuous variables. Multivariate analysis for the primary outcome of remission at 12 months was performed.

Results
A total of 134 patients with CDP on therapy were enrolled, of whom 49 (36.7%) were on ustekinumab, 39 (29.1%) on adalimumab or infliximab, 24 (17.9%) on vedolizumab, and 4 (3.0%) on tofacitinib. Overall, 57 (42.5%) patients were in remission at baseline and 76 (56.7%) patients were in remission at 12 months (Table 1). There were no significant clinical predictors of remission status at 12 months on multivariate analysis.

Among the 57 patients in remission at baseline, 16 (28.1%) developed symptoms and were no longer in remission at 12 months despite a change in biologic therapy in 8 (50.0%), the most common of which was a transition to vedolizumab. Among the 77 patients with symptoms at baseline, 35 (46.7%) achieved remission at 12 months. Of these, 23 (65.7%) remained on the same biologic therapy as enrollment while 12 (34.3%) changed therapy, the most common of which was a transition to adalimumab or infliximab. Among those in remission at 12 months, only 4 were actively using antibiotics (1 new start, 3 continuation from baseline). There was no significant association between biologic patterns and remission status at 12 months. Patients who remained on the same therapy had significantly greater quality of life scores (p=0.03) while patients who switched therapy had significantly less stool urgency (p=0.03) and hematochezia (p=0.04) at 12 months. Clinical assessments at 12 months are provided in Table 2.

Conclusion
In a multicenter prospective cohort of patients with CDP on therapy, approximately 50% with symptoms at enrollment achieved clinical remission at 12 months, the majority of whom did so without a change in biologic or antibiotic therapy.

Saturday
Society: AGA

BACKGROUND: Prevention of postoperative recurrence (POR) in Crohn’s disease (CD) after ileo-colonic (IC) resection is still a highly debated topic. Prophylactic immunosuppression after surgery is currently recommended in presence of at least one clinical risk factor (RF). Due to drug-related adverse events and the relative high cost of biologics, we aimed to determine whether prevention of POR can be postponed and guided by endoscopy in CD patients with only one RF.
METHODS: A multicentre retrospective study was conducted in 12 Italian centres. CD patients with only one RF for POR, including previous intestinal resection, extensive small intestine resection (>50 cm), fistulising phenotype, history of perianal disease, or active smoking were considered. Patients who performed a colonoscopy between 6 to 12 months after curative IC resection were included. Two groups were formed based on whether immunosuppressive therapy was started immediately after surgery (prophylaxis group) or guided by endoscopy (observation group). Primary endpoints were the rates of any endoscopic recurrence (Rutgeerts ≥i2a) and severe endoscopic recurrence (i4) within 12 months after surgery. Secondary outcomes were clinical recurrence (HBI≥5) rates at 6, 12 and 24 months after surgery.
RESULTS: A total of 195 patients were enrolled. Out of all, 61 (31.3%) received immunoprophylaxis at a median time of 32 days [IQR 26-55] after surgery (n=14 infliximab, n=37 adalimumab, n=7 azathioprine, n=3 ustekinumab). Baseline patient characteristics are detailed in Table 1. Particularly, risk factors for POR were homogeneously distributed between the 2 groups. Colonoscopy was performed after a median time of 8 months [IQR 6-11]. No differences between immunoprophylaxis and endoscopy-driven approach was found regarding any endoscopic recurrence (36.1% in prophylaxis group vs 45.5% in observation group, p=0.10) and severe endoscopic recurrence (9.8% in prophylaxis group vs 15.7% in observation group, p=0.15). In 32 patients with a second colonoscopy at a median time of 30.5 months [IQR 22-43.75] after surgery, any recurrence and severe recurrence rates were also similar (p=0.55 and p=0.43, respectively).
Early clinical recurrence at 6 months was reported in 23.4% of patients on immunoprophylaxis vs 31.5% who were not (p=0.43). Clinical recurrence rates between prophylaxis and observation group were also similar at 12 months (17.9% vs 34.8%, respectively, p=0.09) and at 24 months (17.9% vs 24.1%, respectively, p=0.63).
CONCLUSION: In CD patients with only one RF for POR, immediate immunoprophylaxis after curative IC resection does not decrease the rate of early clinical and endoscopic recurrence. Prospective and larger studies are needed to confirm our results.
Background
Early treatment of Crohn’s disease (CD) often involves biologics such as anti-tumor necrosis factor (anti-TNF) agents. Ileocecal resection (ICR), while a therapeutic option in early CD, is generally reserved for complicated CD or when medical treatment fails. We aimed to compare long-term outcomes of ICR and anti-TNF therapy as index treatment for ileocecal CD, initiated within one year of diagnosis, in the Danish nationwide cohort.

Methods
Using cross-linked nationwide registers, we identified all individuals who lived in Denmark and were diagnosed with ileal CD between 2003 and 2018. We included individuals who underwent ICR or received anti-TNF drugs as index treatment for ileocecal CD within one year of diagnosis. We excluded patients who did not have pathology information confirming disease in the ileocecal region. The primary outcome was a composite of CD-related hospitalization, systemic corticosteroid exposure, CD-related surgery, and perianal CD diagnosis. We conducted Cox proportional hazards regression analyses to compare outcomes in the two groups after adjusting for potential confounders. We also determined the proportion of individuals initiated on immunomodulator (IMM), anti-TNF, or no therapy at 5 years after ICR.

Results
Of the 16,443 individuals diagnosed with ileocecal CD between 2003 and 2018, 581 (3.5%) and 698 (4.2%) individuals with confirmed disease in the ileocecal region underwent ICR and received anti-TNF as the index treatment, respectively. The composite outcome occurred in 273 individuals (IR 110.3/100,0 person years (PY)) in the ICR group and in 318 individuals (IR 201.9/100,0 PY) in the anti-TNF group. The risk of the composite outcome was 33% lower in the ICR group compared to the anti-TNF group (aHR 0.67; 95% CI 0.54, 0.83), after adjusting for demographic and clinical variables. On analysis of individual outcomes, ICR was associated with reduced risk of systemic corticosteroid exposure and CD-related surgery, but not CD-related hospitalization or perianal CD diagnosis. Of individuals who underwent ICR, the proportion that was initiated on IMM, anti-TNF treatment or no treatment at 5 years of follow up was 47.5%, 17.1%, and 50.3%, respectively.

Conclusion
These data support the role of ICR as an index treatment for ileocecal CD and challenge the current paradigm of reserving surgery for complicated CD refractory or intolerant to medications. Further studies will help identify characteristics of individuals who needed no treatment after ICR.
Background
We aimed to compare the effectiveness of tofacitinib and ustekinumab in patients with ulcerative colitis (UC) previously exposed to at least one anti-TNF agent.
Methods
In this multicenter study, we retrospectively included consecutive UC adult patients previously exposed to at least one anti-TNF agent, with partial Mayo score (pMS) > 2, having who started tofacitinib or ustekinumab between January 2019 and June 2022.
The primary endpoint was steroid-free clinical remission (pMS ≤ 2) (CFREM) at week 16 (W16).
Secondary endpoints were endoscopic remission (CFREM + Mayo endoscopic score (MES) ≤ 1), and histological remission (CFREM + MES ≤ 1 + Nancy index ≤ 1).
Comparisons were performed using propensity score analyses adjusted on potential confounders.
Results
Overall, 289 patients were included (tofacitinib = 124 patients, ustekinumab = 165 patients). The groups were comparable (tofacitinib vs vedolizumab) for male gender (50.8% vs 43.3%), mean age (40.7 vs 42.9 years), median UC duration (8.6 vs 9.3 years), concomitant use of 5-ASA (13.7% vs 9.7%), steroids (25.0% vs 29.7%), immunosuppressants (7.3% vs 5.5%), and ≥ 2 prior biologics (85.5% vs 82.4%). Tofacitinib group had more pancolitis (55.6% vs 42.4%, p = 0.026) and UC with pMS > 6 (64.5% vs 50.3%, p = 0.016). In our study, 42.1 % of the patients treated with tofacitinib continued using a dose of 10 mgx2/day until W16 while 47.3% of the patients on ustekinumab required dose escalation to 90 mg/4 weeks before W16.
After propensity score analysis, the rate of CFREM at W16 was 37.8% and 35.6% in the tofacitinib and ustekinumab arms, respectively arm (p=0.75). CFREM at W16 was achieved in 43.3% vs 57.1% (p = 0.48) after failure of one biologic, 20.7% vs 37.9% (p=0.16) two biologics and 46.7% vs 23.2% (p=0.047) if ≥ 3 biologics, in tofacitinib and vedolizumab arms, respectively. After primary failure to at least one biologic, the rate of CFREM at W16 was 46.3% on tofacitinib vs 25.9% on ustekinumab (p = 0.13). CFREM at W16 was similar with tofacitinib and ustekinumab in case of more severe UC such as pMS ≥ 6 (40.6% vs 41.5%) and CRP > 30 (27.2% vs 33.0%).
No predictor of tofacitinib effectiveness has been identified. Factors associated with no CFREM at W16 on ustekinumab were male gender (p=0.035), ≥ 3 prior biologics (p=0.013), prior use of tofacitinib (p=0.03), primary failure to at least one biologic (p=0.013).
After propensity score analysis, endoscopic remission was achieved in 17.0% vs 11.7% (p =0.47) and histological remission in 4.4% vs 7.8% (p=0.32) of the patients treated with tofacitinib and ustekinumab, respectively.
Conclusion
Tofacitinib and ustekinumab have similar effectiveness in UC after anti-TNF failure.
However, the efficacy of ustekinumab could be more impacted by prior therapeutic failures.
Introduction
Approximately 15% of patients with ulcerative colitis (UC) will develop Crohn’s disease of the pouch (CDP) after total proctocolectomy with ileal pouch anal anastomosis (IPAA). Data to support the use of biologics or small molecules in patients with CDP is limited and little is known about real-world treatment patterns in these patients. The aim of this study was to evaluate patterns of biologic and small molecule use and assess remission rates in patients with CDP.

Methods
This was a prospective, multicenter study of patients with CDP on therapy. Clinical assessments were performed at baseline and 3, 6, and 12 months after enrollment. The diagnosis of CDP was made by the enrolling physician and was based on the following criteria: inflammation of the pre-pouch ileum, strictures involving the pouch or pre-pouch ileum, and/or fistulae involving the pouch or pre-pouch ileum. Remission was defined as a clinical modified Pouchitis Disease Activity Index score <2. Fisher’s exact test was used to compare categorical variables and the Kruskal-Wallis test was used to compare continuous variables. Multivariate analysis for the primary outcome of remission at 12 months was performed.

Results
A total of 134 patients with CDP on therapy were enrolled, of whom 49 (36.7%) were on ustekinumab, 39 (29.1%) on adalimumab or infliximab, 24 (17.9%) on vedolizumab, and 4 (3.0%) on tofacitinib. Overall, 57 (42.5%) patients were in remission at baseline and 76 (56.7%) patients were in remission at 12 months (Table 1). There were no significant clinical predictors of remission status at 12 months on multivariate analysis.

Among the 57 patients in remission at baseline, 16 (28.1%) developed symptoms and were no longer in remission at 12 months despite a change in biologic therapy in 8 (50.0%), the most common of which was a transition to vedolizumab. Among the 77 patients with symptoms at baseline, 35 (46.7%) achieved remission at 12 months. Of these, 23 (65.7%) remained on the same biologic therapy as enrollment while 12 (34.3%) changed therapy, the most common of which was a transition to adalimumab or infliximab. Among those in remission at 12 months, only 4 were actively using antibiotics (1 new start, 3 continuation from baseline). There was no significant association between biologic patterns and remission status at 12 months. Patients who remained on the same therapy had significantly greater quality of life scores (p=0.03) while patients who switched therapy had significantly less stool urgency (p=0.03) and hematochezia (p=0.04) at 12 months. Clinical assessments at 12 months are provided in Table 2.

Conclusion
In a multicenter prospective cohort of patients with CDP on therapy, approximately 50% with symptoms at enrollment achieved clinical remission at 12 months, the majority of whom did so without a change in biologic or antibiotic therapy.
Background: This study evaluated real-world clinical effectiveness and safety of vedolizumab (VDZ), a gut-selective α4β7-integrin inhibitor and ustekinumab (UST), an IL-12/23 p40 inhibitor, as first-line biologic treatment (Tx) for patients (pts) with Crohn’s disease (CD).

Methods: The EVOLVE Expansion study (NCT05056441) was a multicenter, observational, retrospective cohort study in biologic-naïve pts with CD (≥18 years old) who initiated VDZ or UST Tx in Australia, Belgium or Switzerland from 2016 to 2021. Data were collected from Tx initiation to initiation of chart abstraction, death or loss to follow-up, whichever came first. The time to event analysis was conducted using the Kaplan-Meier method and cumulative rates of clinical response, remission, mucosal healing and Tx persistence were estimated over 12, 24 and 36 months. Serious adverse events (SAEs), serious infections (SIs), CD exacerbations and CD-related surgeries were also evaluated. Inverse probability of treatment weighing was used to balance demographic and clinical characteristics across treatment groups.

Results: 623 biologic-naïve pts with CD (VDZ 347, UST 276) from 31 sites were included. Baseline characteristics are presented in Table 1. Cumulative rates over 36 months were similar between VDZ- and UST-treated pts for clinical response (VDZ 82.0%, UST 84.1%; p=0.87) and clinical remission (VDZ 88.3%, UST 88.5%; p=0.67) (Table 2). Mucosal healing rates were significantly higher in VDZ- versus UST-treated pts (VDZ 91.3%, UST 87.4%, p=0.02), and treatment persistence was higher in UST-treated pts over 36 months (VDZ 70.6%, UST 80.3%; p=0.03). In VDZ cohort, 54 SAEs (including SIs) and 12 SIs occurred in 35/347 (10.1%) and 9/347 (2.6%) pts, respectively, while in UST cohort, 53 SAEs (including SIs) and 5 SIs occurred in 27/276 (9.8%) and 2/276 (0.7%) pts, respectively. There were no significant differences in the risk of CD exacerbations (HR 1.01; 95% CI, 0.68-1.49; p=0.98) and CD-related surgeries (HR 1.80; 95% CI, 0.69-4.73; p=0.23) between VDZ- and UST-treated pts.

Conclusion: In real-world setting, clinical response and clinical remission were similar between VDZ and UST in biologic-naïve pts with CD. However, over 36 months mucosal healing was higher in the VDZ-treated pts, and Tx persistence was higher in UST-treated pts.

09:00am - 10:30am EDT - May 6, 2023 | Room: W194 (McCormick Place)
Jason Shapiro, Moderator; Cathryn Nagler, Moderator
Society: AGA
Type: Research Forum
Society: AGA


Saturday
Society: AGA

Background: Contamination-free oats are considered safe for most patients with celiac disease (CeD). However, we and others have isolated pro-inflammatory oat protein (avenin)-specific CD4+ T cells from the blood and duodenum of some people with CeD, a finding that carries troubling implications for safe oats ingestion in CeD. Does the presence of avenin-specific T cells identify CeD patients susceptible to harm from oats?
Aim: To determine the frequency of symptoms and immune activation in patients with CeD after single-bolus ingestion of purified avenin and then assess symptomatic, immune and clinical (safety) effects after extended avenin ingestion.
Methods: For the first time, food-grade avenin was purified from contamination-free oats to enable feeding studies at high doses not achievable using oats. We employed a series of single-bolus avenin challenges in HLA-DQ2.5+ CeD adults with assessment of symptoms and serum interleukin (IL)-2 at 4 hrs, a highly sensitive marker of gluten-specific T cell activation. Avenin was given in increasing amounts (0.05, 0.1, 0.5, 1, 4, and 6 g) with 4-wk washout periods. Subsequently, in patients with IL-2 responses, avenin was consumed daily for 6 wks at the highest tolerated dose that triggered IL-2. T-cells were assessed using avenin-specific tetramers, serum cytokines (MSD and O-link Inflammation 96-panel) and duodenal histology was examined pre- and post- challenge. A CeD patient undertook a 6 wk wheat gluten challenge as a positive control.
Results: Surprisingly, avenin induced a significant acute IL-2 elevation in 11/29 (38%) CeD patients (mean 16-fold elevation) and adverse symptoms such as pain, diarrhea and vomiting were induced in 60%, with severity correlated to higher IL-2 elevation. Five IL-2 responders then undertook 6-wk avenin challenge. Activated avenin-specific tetramer+ effector memory CD4+ T cells were increased on day 6. Interestingly, after 6 wks of avenin, these had returned to baseline and IL-2 responses after avenin were undetectable; all patients were tolerating avenin without the acute initial symptoms. In the duodenum, a similar frequency of tetramer+ cells were seen at baseline and at 6 wks. Notably, duodenal histology after 6 wks avenin remained normal, in contrast to significant deterioration in the wheat challenged patient. Serum inflammatory cytokines were not elevated by avenin except in one highly symptomatic CeD patient to a similar degree as the wheat challenged patient.
Conclusion: Purified avenin induces acute symptoms and T-cell responses in a subset of “sensitive” CeD patients. Reassuringly, our findings suggest that in most CeD patients oats is unable to sustain a pathogenic immune response above the threshold required for mucosal deterioration, in contrast to wheat gluten. These findings help resolve the discrepancy between clinical oats safety and oats immunity in CeD.

Saturday
Society: AGA

Background: Contamination-free oats are considered safe for most patients with celiac disease (CeD). However, we and others have isolated pro-inflammatory oat protein (avenin)-specific CD4+ T cells from the blood and duodenum of some people with CeD, a finding that carries troubling implications for safe oats ingestion in CeD. Does the presence of avenin-specific T cells identify CeD patients susceptible to harm from oats?
Aim: To determine the frequency of symptoms and immune activation in patients with CeD after single-bolus ingestion of purified avenin and then assess symptomatic, immune and clinical (safety) effects after extended avenin ingestion.
Methods: For the first time, food-grade avenin was purified from contamination-free oats to enable feeding studies at high doses not achievable using oats. We employed a series of single-bolus avenin challenges in HLA-DQ2.5+ CeD adults with assessment of symptoms and serum interleukin (IL)-2 at 4 hrs, a highly sensitive marker of gluten-specific T cell activation. Avenin was given in increasing amounts (0.05, 0.1, 0.5, 1, 4, and 6 g) with 4-wk washout periods. Subsequently, in patients with IL-2 responses, avenin was consumed daily for 6 wks at the highest tolerated dose that triggered IL-2. T-cells were assessed using avenin-specific tetramers, serum cytokines (MSD and O-link Inflammation 96-panel) and duodenal histology was examined pre- and post- challenge. A CeD patient undertook a 6 wk wheat gluten challenge as a positive control.
Results: Surprisingly, avenin induced a significant acute IL-2 elevation in 11/29 (38%) CeD patients (mean 16-fold elevation) and adverse symptoms such as pain, diarrhea and vomiting were induced in 60%, with severity correlated to higher IL-2 elevation. Five IL-2 responders then undertook 6-wk avenin challenge. Activated avenin-specific tetramer+ effector memory CD4+ T cells were increased on day 6. Interestingly, after 6 wks of avenin, these had returned to baseline and IL-2 responses after avenin were undetectable; all patients were tolerating avenin without the acute initial symptoms. In the duodenum, a similar frequency of tetramer+ cells were seen at baseline and at 6 wks. Notably, duodenal histology after 6 wks avenin remained normal, in contrast to significant deterioration in the wheat challenged patient. Serum inflammatory cytokines were not elevated by avenin except in one highly symptomatic CeD patient to a similar degree as the wheat challenged patient.
Conclusion: Purified avenin induces acute symptoms and T-cell responses in a subset of “sensitive” CeD patients. Reassuringly, our findings suggest that in most CeD patients oats is unable to sustain a pathogenic immune response above the threshold required for mucosal deterioration, in contrast to wheat gluten. These findings help resolve the discrepancy between clinical oats safety and oats immunity in CeD.
The gluten-free diet for celiac disease (CeD) is restrictive and often fails to induce complete symptom and/or mucosal disease remission. Central to CeD pathogenesis is the gluten-specific CD4+ T cell that is restricted by HLA-DQ2.5 in over 85% of CeD patients, making HLA-DQ2.5 an attractive target for suppressing gluten-dependent immunity. Recently, a novel anti-HLA-DQ2.5 antibody that specifically recognizes the complex of HLA-DQ2.5 and multiple gluten epitopes was developed (DONQ52).
Aim: To assess the ability of DONQ52 to inhibit CeD patient-derived T cell responses to the most immunogenic wheat gluten peptides encompassing immunodominant T cell epitopes.
Methods: We employed an in vivo gluten challenge model in patients with CeD that affords a quantitative readout of disease-relevant gluten-specific T cell responses. HLA-DQ2.5+ CeD patients undertook a 3-day wheat bread challenge (10g/d gluten) with collection of blood before (D1) and 6 days after (D6) commencing the challenge. Peripheral blood mononuclear cells were isolated and assessed in an interferon-γ enzyme-linked immunosorbent spot assay (ELISpot) testing for responses to gluten peptides encompassing DQ2.5-glia-α1a/α2, DQ2.5-glia-ω1/ω2 and DQ2.5-glia-γ1 and deamidated gliadin protein. The effect of addition of DONQ52 (4 or 40 μg/mL) was assessed and compared to pan-DQ blockade (SPVL3 antibody).
Results: 20 CeD patients completed 3-day wheat challenge and 15/20 (75%) had robust gluten-specific T cell responses to the α- and ω-gliadin peptides and the 33mer on D6. Notably, DONQ52 at both concentrations was highly efficient at inhibiting IFN-γ responses to all stimulatory gluten peptides in all responsive patients, with a mean reduction in response of 88% (33-mer), 89% (DQ2.5-glia-α1a/α2), 63% (DQ2.5-glia-ω1/ω2) and 84% (cocktail of peptides containing DQ2.5-glia-α1a/α2, DQ2.5-glia-ω1/ω2 and DQ2.5-glia-γ1), with DONQ52 at 40 μg/mL. DONQ52 was generally better than Pan-DQ antibody blockade in reducing gluten peptide responses. T cell responses to whole protein (gliadin) were less consistent, but nevertheless, blocking by DONQ52 was seen in 67% of gliadin responders. DONQ52 had no effect on activating non-specific T cell responses when tested using PBMC isolated on D1 prior to gluten challenge.
Conclusion: DONQ52 is highly effective at blocking gluten-specific T cell responses to dominant wheat gluten epitopes. Studies to assess DONQ52 blockade of barley hordein and rye secalin-specific T cells induced by barley and rye challenge, respectively, are underway. Our findings support in vitro data that DONQ52 displays selectivity and broad cross-reactivity against HLA-DQ2.5/gluten peptides and provides proof-of-concept that such an approach has the potential to meaningfully inhibit pathogenic gluten-specific T cell responses in CeD.

Saturday
Society: AGA

Background: Contamination-free oats are considered safe for most patients with celiac disease (CeD). However, we and others have isolated pro-inflammatory oat protein (avenin)-specific CD4+ T cells from the blood and duodenum of some people with CeD, a finding that carries troubling implications for safe oats ingestion in CeD. Does the presence of avenin-specific T cells identify CeD patients susceptible to harm from oats?
Aim: To determine the frequency of symptoms and immune activation in patients with CeD after single-bolus ingestion of purified avenin and then assess symptomatic, immune and clinical (safety) effects after extended avenin ingestion.
Methods: For the first time, food-grade avenin was purified from contamination-free oats to enable feeding studies at high doses not achievable using oats. We employed a series of single-bolus avenin challenges in HLA-DQ2.5+ CeD adults with assessment of symptoms and serum interleukin (IL)-2 at 4 hrs, a highly sensitive marker of gluten-specific T cell activation. Avenin was given in increasing amounts (0.05, 0.1, 0.5, 1, 4, and 6 g) with 4-wk washout periods. Subsequently, in patients with IL-2 responses, avenin was consumed daily for 6 wks at the highest tolerated dose that triggered IL-2. T-cells were assessed using avenin-specific tetramers, serum cytokines (MSD and O-link Inflammation 96-panel) and duodenal histology was examined pre- and post- challenge. A CeD patient undertook a 6 wk wheat gluten challenge as a positive control.
Results: Surprisingly, avenin induced a significant acute IL-2 elevation in 11/29 (38%) CeD patients (mean 16-fold elevation) and adverse symptoms such as pain, diarrhea and vomiting were induced in 60%, with severity correlated to higher IL-2 elevation. Five IL-2 responders then undertook 6-wk avenin challenge. Activated avenin-specific tetramer+ effector memory CD4+ T cells were increased on day 6. Interestingly, after 6 wks of avenin, these had returned to baseline and IL-2 responses after avenin were undetectable; all patients were tolerating avenin without the acute initial symptoms. In the duodenum, a similar frequency of tetramer+ cells were seen at baseline and at 6 wks. Notably, duodenal histology after 6 wks avenin remained normal, in contrast to significant deterioration in the wheat challenged patient. Serum inflammatory cytokines were not elevated by avenin except in one highly symptomatic CeD patient to a similar degree as the wheat challenged patient.
Conclusion: Purified avenin induces acute symptoms and T-cell responses in a subset of “sensitive” CeD patients. Reassuringly, our findings suggest that in most CeD patients oats is unable to sustain a pathogenic immune response above the threshold required for mucosal deterioration, in contrast to wheat gluten. These findings help resolve the discrepancy between clinical oats safety and oats immunity in CeD.
The gluten-free diet for celiac disease (CeD) is restrictive and often fails to induce complete symptom and/or mucosal disease remission. Central to CeD pathogenesis is the gluten-specific CD4+ T cell that is restricted by HLA-DQ2.5 in over 85% of CeD patients, making HLA-DQ2.5 an attractive target for suppressing gluten-dependent immunity. Recently, a novel anti-HLA-DQ2.5 antibody that specifically recognizes the complex of HLA-DQ2.5 and multiple gluten epitopes was developed (DONQ52).
Aim: To assess the ability of DONQ52 to inhibit CeD patient-derived T cell responses to the most immunogenic wheat gluten peptides encompassing immunodominant T cell epitopes.
Methods: We employed an in vivo gluten challenge model in patients with CeD that affords a quantitative readout of disease-relevant gluten-specific T cell responses. HLA-DQ2.5+ CeD patients undertook a 3-day wheat bread challenge (10g/d gluten) with collection of blood before (D1) and 6 days after (D6) commencing the challenge. Peripheral blood mononuclear cells were isolated and assessed in an interferon-γ enzyme-linked immunosorbent spot assay (ELISpot) testing for responses to gluten peptides encompassing DQ2.5-glia-α1a/α2, DQ2.5-glia-ω1/ω2 and DQ2.5-glia-γ1 and deamidated gliadin protein. The effect of addition of DONQ52 (4 or 40 μg/mL) was assessed and compared to pan-DQ blockade (SPVL3 antibody).
Results: 20 CeD patients completed 3-day wheat challenge and 15/20 (75%) had robust gluten-specific T cell responses to the α- and ω-gliadin peptides and the 33mer on D6. Notably, DONQ52 at both concentrations was highly efficient at inhibiting IFN-γ responses to all stimulatory gluten peptides in all responsive patients, with a mean reduction in response of 88% (33-mer), 89% (DQ2.5-glia-α1a/α2), 63% (DQ2.5-glia-ω1/ω2) and 84% (cocktail of peptides containing DQ2.5-glia-α1a/α2, DQ2.5-glia-ω1/ω2 and DQ2.5-glia-γ1), with DONQ52 at 40 μg/mL. DONQ52 was generally better than Pan-DQ antibody blockade in reducing gluten peptide responses. T cell responses to whole protein (gliadin) were less consistent, but nevertheless, blocking by DONQ52 was seen in 67% of gliadin responders. DONQ52 had no effect on activating non-specific T cell responses when tested using PBMC isolated on D1 prior to gluten challenge.
Conclusion: DONQ52 is highly effective at blocking gluten-specific T cell responses to dominant wheat gluten epitopes. Studies to assess DONQ52 blockade of barley hordein and rye secalin-specific T cells induced by barley and rye challenge, respectively, are underway. Our findings support in vitro data that DONQ52 displays selectivity and broad cross-reactivity against HLA-DQ2.5/gluten peptides and provides proof-of-concept that such an approach has the potential to meaningfully inhibit pathogenic gluten-specific T cell responses in CeD.
Background and Aim: The worldwide prevalence of food sensitivities, including food allergies and autoimmune conditions, such as celiac disease (CeD), has increased in the past decades. This suggests that co-factors, linked to industrialization, are involved. One understudied factor typically used in processed foods and considered harmless, are inorganic nanoparticles (NPs). Our aim was to investigate whether daily exposure to the NP-structured silicon dioxide (SiO2), employed as an anticaking agent in powdered foods, including infant formula, alters oral tolerance (OT) induction to ovalbumin (OVA), and increases severity of gluten sensitivity in mice.
Methods: An OT induction model to OVA was used in C57BL/6J mice that were orally exposed to food-grade (fg) SiO2 for 60 days (10mg/kg body weight/day) in water suspension (gastric gavage) or incorporated into food pellets (solid matrix). Controls were gavaged with water. The gut immune response and immune cell populations induced were analysed by flow cytometry. Non-obese diabetic (NOD) mice expressing the CeD susceptibility gene HLA-DQ8 (NOD/DQ8) were exposed to fg-SiO2, and subsequently immunized with gluten, the main environmental trigger of CeD. Small intestinal immunopathology was investigated at endpoint through assessment of villus-to-crypt ratios and intraepithelial lymphocyte (IEL) counts.
Results: fg-SiO2 at human dietary levels led to low-grade intestinal inflammation evidenced by higher pro-inflammatory cytokines, such as IFN-γ, and lower anti-inflammatory cytokines, including IL-10 and TGF-β, known mediators in OT. After OT induction to OVA, fg-SiO2 exposure was associated with decreased expansion of IL-10 and TGF-β-producing T cells and the development of a pro-inflammatory Th1 inflammatory response. fg-SiO2 exposure through gastric gavage, but not through food pellets, decreased the frequency of CD103+ dendritic cells. In NOD/DQ8 mice, fg-SiO2 decreased villus-to-crypt ratios, increased IELs counts, and enhanced the Th1 inflammatory response induced by immunization to gluten.
Conclusions: Chronic oral exposure to the food additive SiO2 blocked the establishment of OT in the gut leading to intestinal inflammation and worsening of gluten-induced immunopathology in NOD/DQ8 mice. The results should prompt investigation on the link between SiO2 exposure and food sensitivities in humans.

Saturday
09:45am - 10:00am EDT - May 6, 2023 | Room: W194 (McCormick Place)
Society: AGA
Type: Research Forum
Society: AGA

Background: Contamination-free oats are considered safe for most patients with celiac disease (CeD). However, we and others have isolated pro-inflammatory oat protein (avenin)-specific CD4+ T cells from the blood and duodenum of some people with CeD, a finding that carries troubling implications for safe oats ingestion in CeD. Does the presence of avenin-specific T cells identify CeD patients susceptible to harm from oats?
Aim: To determine the frequency of symptoms and immune activation in patients with CeD after single-bolus ingestion of purified avenin and then assess symptomatic, immune and clinical (safety) effects after extended avenin ingestion.
Methods: For the first time, food-grade avenin was purified from contamination-free oats to enable feeding studies at high doses not achievable using oats. We employed a series of single-bolus avenin challenges in HLA-DQ2.5+ CeD adults with assessment of symptoms and serum interleukin (IL)-2 at 4 hrs, a highly sensitive marker of gluten-specific T cell activation. Avenin was given in increasing amounts (0.05, 0.1, 0.5, 1, 4, and 6 g) with 4-wk washout periods. Subsequently, in patients with IL-2 responses, avenin was consumed daily for 6 wks at the highest tolerated dose that triggered IL-2. T-cells were assessed using avenin-specific tetramers, serum cytokines (MSD and O-link Inflammation 96-panel) and duodenal histology was examined pre- and post- challenge. A CeD patient undertook a 6 wk wheat gluten challenge as a positive control.
Results: Surprisingly, avenin induced a significant acute IL-2 elevation in 11/29 (38%) CeD patients (mean 16-fold elevation) and adverse symptoms such as pain, diarrhea and vomiting were induced in 60%, with severity correlated to higher IL-2 elevation. Five IL-2 responders then undertook 6-wk avenin challenge. Activated avenin-specific tetramer+ effector memory CD4+ T cells were increased on day 6. Interestingly, after 6 wks of avenin, these had returned to baseline and IL-2 responses after avenin were undetectable; all patients were tolerating avenin without the acute initial symptoms. In the duodenum, a similar frequency of tetramer+ cells were seen at baseline and at 6 wks. Notably, duodenal histology after 6 wks avenin remained normal, in contrast to significant deterioration in the wheat challenged patient. Serum inflammatory cytokines were not elevated by avenin except in one highly symptomatic CeD patient to a similar degree as the wheat challenged patient.
Conclusion: Purified avenin induces acute symptoms and T-cell responses in a subset of “sensitive” CeD patients. Reassuringly, our findings suggest that in most CeD patients oats is unable to sustain a pathogenic immune response above the threshold required for mucosal deterioration, in contrast to wheat gluten. These findings help resolve the discrepancy between clinical oats safety and oats immunity in CeD.
The gluten-free diet for celiac disease (CeD) is restrictive and often fails to induce complete symptom and/or mucosal disease remission. Central to CeD pathogenesis is the gluten-specific CD4+ T cell that is restricted by HLA-DQ2.5 in over 85% of CeD patients, making HLA-DQ2.5 an attractive target for suppressing gluten-dependent immunity. Recently, a novel anti-HLA-DQ2.5 antibody that specifically recognizes the complex of HLA-DQ2.5 and multiple gluten epitopes was developed (DONQ52).
Aim: To assess the ability of DONQ52 to inhibit CeD patient-derived T cell responses to the most immunogenic wheat gluten peptides encompassing immunodominant T cell epitopes.
Methods: We employed an in vivo gluten challenge model in patients with CeD that affords a quantitative readout of disease-relevant gluten-specific T cell responses. HLA-DQ2.5+ CeD patients undertook a 3-day wheat bread challenge (10g/d gluten) with collection of blood before (D1) and 6 days after (D6) commencing the challenge. Peripheral blood mononuclear cells were isolated and assessed in an interferon-γ enzyme-linked immunosorbent spot assay (ELISpot) testing for responses to gluten peptides encompassing DQ2.5-glia-α1a/α2, DQ2.5-glia-ω1/ω2 and DQ2.5-glia-γ1 and deamidated gliadin protein. The effect of addition of DONQ52 (4 or 40 μg/mL) was assessed and compared to pan-DQ blockade (SPVL3 antibody).
Results: 20 CeD patients completed 3-day wheat challenge and 15/20 (75%) had robust gluten-specific T cell responses to the α- and ω-gliadin peptides and the 33mer on D6. Notably, DONQ52 at both concentrations was highly efficient at inhibiting IFN-γ responses to all stimulatory gluten peptides in all responsive patients, with a mean reduction in response of 88% (33-mer), 89% (DQ2.5-glia-α1a/α2), 63% (DQ2.5-glia-ω1/ω2) and 84% (cocktail of peptides containing DQ2.5-glia-α1a/α2, DQ2.5-glia-ω1/ω2 and DQ2.5-glia-γ1), with DONQ52 at 40 μg/mL. DONQ52 was generally better than Pan-DQ antibody blockade in reducing gluten peptide responses. T cell responses to whole protein (gliadin) were less consistent, but nevertheless, blocking by DONQ52 was seen in 67% of gliadin responders. DONQ52 had no effect on activating non-specific T cell responses when tested using PBMC isolated on D1 prior to gluten challenge.
Conclusion: DONQ52 is highly effective at blocking gluten-specific T cell responses to dominant wheat gluten epitopes. Studies to assess DONQ52 blockade of barley hordein and rye secalin-specific T cells induced by barley and rye challenge, respectively, are underway. Our findings support in vitro data that DONQ52 displays selectivity and broad cross-reactivity against HLA-DQ2.5/gluten peptides and provides proof-of-concept that such an approach has the potential to meaningfully inhibit pathogenic gluten-specific T cell responses in CeD.
Background and Aim: The worldwide prevalence of food sensitivities, including food allergies and autoimmune conditions, such as celiac disease (CeD), has increased in the past decades. This suggests that co-factors, linked to industrialization, are involved. One understudied factor typically used in processed foods and considered harmless, are inorganic nanoparticles (NPs). Our aim was to investigate whether daily exposure to the NP-structured silicon dioxide (SiO2), employed as an anticaking agent in powdered foods, including infant formula, alters oral tolerance (OT) induction to ovalbumin (OVA), and increases severity of gluten sensitivity in mice.
Methods: An OT induction model to OVA was used in C57BL/6J mice that were orally exposed to food-grade (fg) SiO2 for 60 days (10mg/kg body weight/day) in water suspension (gastric gavage) or incorporated into food pellets (solid matrix). Controls were gavaged with water. The gut immune response and immune cell populations induced were analysed by flow cytometry. Non-obese diabetic (NOD) mice expressing the CeD susceptibility gene HLA-DQ8 (NOD/DQ8) were exposed to fg-SiO2, and subsequently immunized with gluten, the main environmental trigger of CeD. Small intestinal immunopathology was investigated at endpoint through assessment of villus-to-crypt ratios and intraepithelial lymphocyte (IEL) counts.
Results: fg-SiO2 at human dietary levels led to low-grade intestinal inflammation evidenced by higher pro-inflammatory cytokines, such as IFN-γ, and lower anti-inflammatory cytokines, including IL-10 and TGF-β, known mediators in OT. After OT induction to OVA, fg-SiO2 exposure was associated with decreased expansion of IL-10 and TGF-β-producing T cells and the development of a pro-inflammatory Th1 inflammatory response. fg-SiO2 exposure through gastric gavage, but not through food pellets, decreased the frequency of CD103+ dendritic cells. In NOD/DQ8 mice, fg-SiO2 decreased villus-to-crypt ratios, increased IELs counts, and enhanced the Th1 inflammatory response induced by immunization to gluten.
Conclusions: Chronic oral exposure to the food additive SiO2 blocked the establishment of OT in the gut leading to intestinal inflammation and worsening of gluten-induced immunopathology in NOD/DQ8 mice. The results should prompt investigation on the link between SiO2 exposure and food sensitivities in humans.
Background: The incidence of celiac disease (CD) has increased over the last decades, especially in females and children. It’s not clear if this is a true increase or due to the availability of highly sensitive testing and increased awareness. Recent reports suggest that CD incidence reached its peak and starting to plateau in many countries over the world. Our study aims to update the CD incidence trend over the last two decades in a well-defined US population.
Methods: Using the Rochester Epidemiology Project (REP) data, we reviewed the electronic health records of both Mayo Clinic and Olmsted Medical Center between January 01, 2000, and December 31, 2021. We identified all CD patients who were diagnosed during the study periods and resided in Olmsted County. Incidence rates were calculated by age, sex, and calendar year and standardized to the 2020 US population.
Results: We identified a total of 662 patients who were diagnosed with CD during the study period. Of those 182 (27%) were children and 424 (64%) were females. The CD incidence rate was higher at the end of the study period at 16.7 (2000-2002) vs 10.3 (2018-2021) per 100.000 person-year. The overall CD incidence rate peaked at 26.4 per 100.000 person-year between 2009 and 2011 and seems to have plateaued and trended down for adults after 2011 especially patients who were > 65 years at diagnosis. On the other hand, the CD incidence rate continued to increase in children. The CD incidence rate in younger children aged (0-10) years at diagnosis is continuing to increase over the last two decades from 11 (2000-2002) to 30 (2018-2021) per 100.000 person-year. There was no significant difference in incidence trend over the last two decades based on gender although females consistently had higher incidence. Figure1
Conclusion: Even though the overall CD incidence rate seems to be plateauing in Olmsted County. CD incidence rate continues to increase in children, which can reflect a shift to earlier diagnosis, or due to a time-based environmental condition(s), that is losing its effect on older patients but affects children as new arrivals to the risk environment.
Sex Adjusted Incidence Rate of Celiac Disease by Age groups between 2000-2021

Sex Adjusted Incidence Rate of Celiac Disease by Age groups between 2000-2021


Saturday
10:00am - 10:15am EDT - May 6, 2023 | Room: W194 (McCormick Place)
Society: AGA
Type: Research Forum
Society: AGA

Background: Contamination-free oats are considered safe for most patients with celiac disease (CeD). However, we and others have isolated pro-inflammatory oat protein (avenin)-specific CD4+ T cells from the blood and duodenum of some people with CeD, a finding that carries troubling implications for safe oats ingestion in CeD. Does the presence of avenin-specific T cells identify CeD patients susceptible to harm from oats?
Aim: To determine the frequency of symptoms and immune activation in patients with CeD after single-bolus ingestion of purified avenin and then assess symptomatic, immune and clinical (safety) effects after extended avenin ingestion.
Methods: For the first time, food-grade avenin was purified from contamination-free oats to enable feeding studies at high doses not achievable using oats. We employed a series of single-bolus avenin challenges in HLA-DQ2.5+ CeD adults with assessment of symptoms and serum interleukin (IL)-2 at 4 hrs, a highly sensitive marker of gluten-specific T cell activation. Avenin was given in increasing amounts (0.05, 0.1, 0.5, 1, 4, and 6 g) with 4-wk washout periods. Subsequently, in patients with IL-2 responses, avenin was consumed daily for 6 wks at the highest tolerated dose that triggered IL-2. T-cells were assessed using avenin-specific tetramers, serum cytokines (MSD and O-link Inflammation 96-panel) and duodenal histology was examined pre- and post- challenge. A CeD patient undertook a 6 wk wheat gluten challenge as a positive control.
Results: Surprisingly, avenin induced a significant acute IL-2 elevation in 11/29 (38%) CeD patients (mean 16-fold elevation) and adverse symptoms such as pain, diarrhea and vomiting were induced in 60%, with severity correlated to higher IL-2 elevation. Five IL-2 responders then undertook 6-wk avenin challenge. Activated avenin-specific tetramer+ effector memory CD4+ T cells were increased on day 6. Interestingly, after 6 wks of avenin, these had returned to baseline and IL-2 responses after avenin were undetectable; all patients were tolerating avenin without the acute initial symptoms. In the duodenum, a similar frequency of tetramer+ cells were seen at baseline and at 6 wks. Notably, duodenal histology after 6 wks avenin remained normal, in contrast to significant deterioration in the wheat challenged patient. Serum inflammatory cytokines were not elevated by avenin except in one highly symptomatic CeD patient to a similar degree as the wheat challenged patient.
Conclusion: Purified avenin induces acute symptoms and T-cell responses in a subset of “sensitive” CeD patients. Reassuringly, our findings suggest that in most CeD patients oats is unable to sustain a pathogenic immune response above the threshold required for mucosal deterioration, in contrast to wheat gluten. These findings help resolve the discrepancy between clinical oats safety and oats immunity in CeD.
The gluten-free diet for celiac disease (CeD) is restrictive and often fails to induce complete symptom and/or mucosal disease remission. Central to CeD pathogenesis is the gluten-specific CD4+ T cell that is restricted by HLA-DQ2.5 in over 85% of CeD patients, making HLA-DQ2.5 an attractive target for suppressing gluten-dependent immunity. Recently, a novel anti-HLA-DQ2.5 antibody that specifically recognizes the complex of HLA-DQ2.5 and multiple gluten epitopes was developed (DONQ52).
Aim: To assess the ability of DONQ52 to inhibit CeD patient-derived T cell responses to the most immunogenic wheat gluten peptides encompassing immunodominant T cell epitopes.
Methods: We employed an in vivo gluten challenge model in patients with CeD that affords a quantitative readout of disease-relevant gluten-specific T cell responses. HLA-DQ2.5+ CeD patients undertook a 3-day wheat bread challenge (10g/d gluten) with collection of blood before (D1) and 6 days after (D6) commencing the challenge. Peripheral blood mononuclear cells were isolated and assessed in an interferon-γ enzyme-linked immunosorbent spot assay (ELISpot) testing for responses to gluten peptides encompassing DQ2.5-glia-α1a/α2, DQ2.5-glia-ω1/ω2 and DQ2.5-glia-γ1 and deamidated gliadin protein. The effect of addition of DONQ52 (4 or 40 μg/mL) was assessed and compared to pan-DQ blockade (SPVL3 antibody).
Results: 20 CeD patients completed 3-day wheat challenge and 15/20 (75%) had robust gluten-specific T cell responses to the α- and ω-gliadin peptides and the 33mer on D6. Notably, DONQ52 at both concentrations was highly efficient at inhibiting IFN-γ responses to all stimulatory gluten peptides in all responsive patients, with a mean reduction in response of 88% (33-mer), 89% (DQ2.5-glia-α1a/α2), 63% (DQ2.5-glia-ω1/ω2) and 84% (cocktail of peptides containing DQ2.5-glia-α1a/α2, DQ2.5-glia-ω1/ω2 and DQ2.5-glia-γ1), with DONQ52 at 40 μg/mL. DONQ52 was generally better than Pan-DQ antibody blockade in reducing gluten peptide responses. T cell responses to whole protein (gliadin) were less consistent, but nevertheless, blocking by DONQ52 was seen in 67% of gliadin responders. DONQ52 had no effect on activating non-specific T cell responses when tested using PBMC isolated on D1 prior to gluten challenge.
Conclusion: DONQ52 is highly effective at blocking gluten-specific T cell responses to dominant wheat gluten epitopes. Studies to assess DONQ52 blockade of barley hordein and rye secalin-specific T cells induced by barley and rye challenge, respectively, are underway. Our findings support in vitro data that DONQ52 displays selectivity and broad cross-reactivity against HLA-DQ2.5/gluten peptides and provides proof-of-concept that such an approach has the potential to meaningfully inhibit pathogenic gluten-specific T cell responses in CeD.
Background and Aim: The worldwide prevalence of food sensitivities, including food allergies and autoimmune conditions, such as celiac disease (CeD), has increased in the past decades. This suggests that co-factors, linked to industrialization, are involved. One understudied factor typically used in processed foods and considered harmless, are inorganic nanoparticles (NPs). Our aim was to investigate whether daily exposure to the NP-structured silicon dioxide (SiO2), employed as an anticaking agent in powdered foods, including infant formula, alters oral tolerance (OT) induction to ovalbumin (OVA), and increases severity of gluten sensitivity in mice.
Methods: An OT induction model to OVA was used in C57BL/6J mice that were orally exposed to food-grade (fg) SiO2 for 60 days (10mg/kg body weight/day) in water suspension (gastric gavage) or incorporated into food pellets (solid matrix). Controls were gavaged with water. The gut immune response and immune cell populations induced were analysed by flow cytometry. Non-obese diabetic (NOD) mice expressing the CeD susceptibility gene HLA-DQ8 (NOD/DQ8) were exposed to fg-SiO2, and subsequently immunized with gluten, the main environmental trigger of CeD. Small intestinal immunopathology was investigated at endpoint through assessment of villus-to-crypt ratios and intraepithelial lymphocyte (IEL) counts.
Results: fg-SiO2 at human dietary levels led to low-grade intestinal inflammation evidenced by higher pro-inflammatory cytokines, such as IFN-γ, and lower anti-inflammatory cytokines, including IL-10 and TGF-β, known mediators in OT. After OT induction to OVA, fg-SiO2 exposure was associated with decreased expansion of IL-10 and TGF-β-producing T cells and the development of a pro-inflammatory Th1 inflammatory response. fg-SiO2 exposure through gastric gavage, but not through food pellets, decreased the frequency of CD103+ dendritic cells. In NOD/DQ8 mice, fg-SiO2 decreased villus-to-crypt ratios, increased IELs counts, and enhanced the Th1 inflammatory response induced by immunization to gluten.
Conclusions: Chronic oral exposure to the food additive SiO2 blocked the establishment of OT in the gut leading to intestinal inflammation and worsening of gluten-induced immunopathology in NOD/DQ8 mice. The results should prompt investigation on the link between SiO2 exposure and food sensitivities in humans.
Background: The incidence of celiac disease (CD) has increased over the last decades, especially in females and children. It’s not clear if this is a true increase or due to the availability of highly sensitive testing and increased awareness. Recent reports suggest that CD incidence reached its peak and starting to plateau in many countries over the world. Our study aims to update the CD incidence trend over the last two decades in a well-defined US population.
Methods: Using the Rochester Epidemiology Project (REP) data, we reviewed the electronic health records of both Mayo Clinic and Olmsted Medical Center between January 01, 2000, and December 31, 2021. We identified all CD patients who were diagnosed during the study periods and resided in Olmsted County. Incidence rates were calculated by age, sex, and calendar year and standardized to the 2020 US population.
Results: We identified a total of 662 patients who were diagnosed with CD during the study period. Of those 182 (27%) were children and 424 (64%) were females. The CD incidence rate was higher at the end of the study period at 16.7 (2000-2002) vs 10.3 (2018-2021) per 100.000 person-year. The overall CD incidence rate peaked at 26.4 per 100.000 person-year between 2009 and 2011 and seems to have plateaued and trended down for adults after 2011 especially patients who were > 65 years at diagnosis. On the other hand, the CD incidence rate continued to increase in children. The CD incidence rate in younger children aged (0-10) years at diagnosis is continuing to increase over the last two decades from 11 (2000-2002) to 30 (2018-2021) per 100.000 person-year. There was no significant difference in incidence trend over the last two decades based on gender although females consistently had higher incidence. Figure1
Conclusion: Even though the overall CD incidence rate seems to be plateauing in Olmsted County. CD incidence rate continues to increase in children, which can reflect a shift to earlier diagnosis, or due to a time-based environmental condition(s), that is losing its effect on older patients but affects children as new arrivals to the risk environment.
Sex Adjusted Incidence Rate of Celiac Disease by Age groups between 2000-2021

Sex Adjusted Incidence Rate of Celiac Disease by Age groups between 2000-2021

INTRODUCTION: Alpha-gal syndrome (AGS) is an immunoglobulin E (IgE) mediated delayed hypersensitivity reaction to galactose-alpha-1,3-galactose (alpha-gal), a carbohydrate on the cells of non-primate mammals. Sensitization is thought to be secondary to ectoparasitic bites, primarily the Lone Star tick endemic to the Southeastern and Eastern United States. Angioedema, anaphylaxis, urticaria, and/or gastrointestinal symptoms occurring 2 to 6 hours following ingestion of non-primate mammalian derived products is the classic presentation. There are reports of a primarily gastrointestinal phenotype of AGS in adults. We sought to determine clinical presentation and response to dietary management of patients with alpha-gal sensitization who presented to a pediatric gastroenterology clinic in an endemic area.
METHODS: We performed a retrospective chart review on patients ages 0-19 from January 1st, 2017, through April 1st, 2022, that were tested for alpha-gal specific IgE (sIgE) at Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, TN. We assessed charts of patients tested through the pediatric gastroenterology clinic to identify demographic data, clinical presentation, and response to elimination diet. Positive alpha-gal was defined as > 0.10 kU/L (Viracor). sIgE for beef, lamb/mutton, and pork (positive > 0.35 kU/L) were reported. Chi-squared and Fisher Exact tests were used for categorical data and Wilcoxon rank-sum test for continuous variables. One way ANOVA was used when comparing response to dietary elimination.
RESULTS: We identified 199 patients who had testing for AGS of which 20.1% (n=40) had a positive alpha-gal sIgE. Positive patients were more likely to be male (67.5% vs 40.9%, p=0.003) and have a known tick exposure (40% vs 11.9%, p<0.001). Positive patients were more likely to have additional symptoms of classic AGS (urticaria, angioedema, etc.) beyond GI symptoms, but 31/40 (77.5%) reported GI symptoms alone. Of 40 patients with positive testing, 30 attempted dietary elimination. Eight (27%) saw complete improvement in their symptoms, 8 (27%) saw partial improvement and 14 (47%) saw no improvement. Patients who improved with dietary elimination were more likely to be male and had a non-significant trend for higher overall specific IgE against alpha-gal, but it was higher sIgE for beef, lamb, and pork that was statistically significant as a predictor of elimination response, compared to those that did not experience improvement.
CONCLUSIONS: In an area endemic for alpha-gal, 20.1% of pediatric patients tested positive for alpha-gal sIgE after evaluation in a pediatric gastroenterology clinic and the majority presented with GI symptoms alone. At least 40% of these patients responded to dietary elimination. Responders were more likely to be male and have higher levels of sIgE for beef, lamb, and pork.

Saturday
Society: AGA

Background: Contamination-free oats are considered safe for most patients with celiac disease (CeD). However, we and others have isolated pro-inflammatory oat protein (avenin)-specific CD4+ T cells from the blood and duodenum of some people with CeD, a finding that carries troubling implications for safe oats ingestion in CeD. Does the presence of avenin-specific T cells identify CeD patients susceptible to harm from oats?
Aim: To determine the frequency of symptoms and immune activation in patients with CeD after single-bolus ingestion of purified avenin and then assess symptomatic, immune and clinical (safety) effects after extended avenin ingestion.
Methods: For the first time, food-grade avenin was purified from contamination-free oats to enable feeding studies at high doses not achievable using oats. We employed a series of single-bolus avenin challenges in HLA-DQ2.5+ CeD adults with assessment of symptoms and serum interleukin (IL)-2 at 4 hrs, a highly sensitive marker of gluten-specific T cell activation. Avenin was given in increasing amounts (0.05, 0.1, 0.5, 1, 4, and 6 g) with 4-wk washout periods. Subsequently, in patients with IL-2 responses, avenin was consumed daily for 6 wks at the highest tolerated dose that triggered IL-2. T-cells were assessed using avenin-specific tetramers, serum cytokines (MSD and O-link Inflammation 96-panel) and duodenal histology was examined pre- and post- challenge. A CeD patient undertook a 6 wk wheat gluten challenge as a positive control.
Results: Surprisingly, avenin induced a significant acute IL-2 elevation in 11/29 (38%) CeD patients (mean 16-fold elevation) and adverse symptoms such as pain, diarrhea and vomiting were induced in 60%, with severity correlated to higher IL-2 elevation. Five IL-2 responders then undertook 6-wk avenin challenge. Activated avenin-specific tetramer+ effector memory CD4+ T cells were increased on day 6. Interestingly, after 6 wks of avenin, these had returned to baseline and IL-2 responses after avenin were undetectable; all patients were tolerating avenin without the acute initial symptoms. In the duodenum, a similar frequency of tetramer+ cells were seen at baseline and at 6 wks. Notably, duodenal histology after 6 wks avenin remained normal, in contrast to significant deterioration in the wheat challenged patient. Serum inflammatory cytokines were not elevated by avenin except in one highly symptomatic CeD patient to a similar degree as the wheat challenged patient.
Conclusion: Purified avenin induces acute symptoms and T-cell responses in a subset of “sensitive” CeD patients. Reassuringly, our findings suggest that in most CeD patients oats is unable to sustain a pathogenic immune response above the threshold required for mucosal deterioration, in contrast to wheat gluten. These findings help resolve the discrepancy between clinical oats safety and oats immunity in CeD.
The gluten-free diet for celiac disease (CeD) is restrictive and often fails to induce complete symptom and/or mucosal disease remission. Central to CeD pathogenesis is the gluten-specific CD4+ T cell that is restricted by HLA-DQ2.5 in over 85% of CeD patients, making HLA-DQ2.5 an attractive target for suppressing gluten-dependent immunity. Recently, a novel anti-HLA-DQ2.5 antibody that specifically recognizes the complex of HLA-DQ2.5 and multiple gluten epitopes was developed (DONQ52).
Aim: To assess the ability of DONQ52 to inhibit CeD patient-derived T cell responses to the most immunogenic wheat gluten peptides encompassing immunodominant T cell epitopes.
Methods: We employed an in vivo gluten challenge model in patients with CeD that affords a quantitative readout of disease-relevant gluten-specific T cell responses. HLA-DQ2.5+ CeD patients undertook a 3-day wheat bread challenge (10g/d gluten) with collection of blood before (D1) and 6 days after (D6) commencing the challenge. Peripheral blood mononuclear cells were isolated and assessed in an interferon-γ enzyme-linked immunosorbent spot assay (ELISpot) testing for responses to gluten peptides encompassing DQ2.5-glia-α1a/α2, DQ2.5-glia-ω1/ω2 and DQ2.5-glia-γ1 and deamidated gliadin protein. The effect of addition of DONQ52 (4 or 40 μg/mL) was assessed and compared to pan-DQ blockade (SPVL3 antibody).
Results: 20 CeD patients completed 3-day wheat challenge and 15/20 (75%) had robust gluten-specific T cell responses to the α- and ω-gliadin peptides and the 33mer on D6. Notably, DONQ52 at both concentrations was highly efficient at inhibiting IFN-γ responses to all stimulatory gluten peptides in all responsive patients, with a mean reduction in response of 88% (33-mer), 89% (DQ2.5-glia-α1a/α2), 63% (DQ2.5-glia-ω1/ω2) and 84% (cocktail of peptides containing DQ2.5-glia-α1a/α2, DQ2.5-glia-ω1/ω2 and DQ2.5-glia-γ1), with DONQ52 at 40 μg/mL. DONQ52 was generally better than Pan-DQ antibody blockade in reducing gluten peptide responses. T cell responses to whole protein (gliadin) were less consistent, but nevertheless, blocking by DONQ52 was seen in 67% of gliadin responders. DONQ52 had no effect on activating non-specific T cell responses when tested using PBMC isolated on D1 prior to gluten challenge.
Conclusion: DONQ52 is highly effective at blocking gluten-specific T cell responses to dominant wheat gluten epitopes. Studies to assess DONQ52 blockade of barley hordein and rye secalin-specific T cells induced by barley and rye challenge, respectively, are underway. Our findings support in vitro data that DONQ52 displays selectivity and broad cross-reactivity against HLA-DQ2.5/gluten peptides and provides proof-of-concept that such an approach has the potential to meaningfully inhibit pathogenic gluten-specific T cell responses in CeD.
Background and Aim: The worldwide prevalence of food sensitivities, including food allergies and autoimmune conditions, such as celiac disease (CeD), has increased in the past decades. This suggests that co-factors, linked to industrialization, are involved. One understudied factor typically used in processed foods and considered harmless, are inorganic nanoparticles (NPs). Our aim was to investigate whether daily exposure to the NP-structured silicon dioxide (SiO2), employed as an anticaking agent in powdered foods, including infant formula, alters oral tolerance (OT) induction to ovalbumin (OVA), and increases severity of gluten sensitivity in mice.
Methods: An OT induction model to OVA was used in C57BL/6J mice that were orally exposed to food-grade (fg) SiO2 for 60 days (10mg/kg body weight/day) in water suspension (gastric gavage) or incorporated into food pellets (solid matrix). Controls were gavaged with water. The gut immune response and immune cell populations induced were analysed by flow cytometry. Non-obese diabetic (NOD) mice expressing the CeD susceptibility gene HLA-DQ8 (NOD/DQ8) were exposed to fg-SiO2, and subsequently immunized with gluten, the main environmental trigger of CeD. Small intestinal immunopathology was investigated at endpoint through assessment of villus-to-crypt ratios and intraepithelial lymphocyte (IEL) counts.
Results: fg-SiO2 at human dietary levels led to low-grade intestinal inflammation evidenced by higher pro-inflammatory cytokines, such as IFN-γ, and lower anti-inflammatory cytokines, including IL-10 and TGF-β, known mediators in OT. After OT induction to OVA, fg-SiO2 exposure was associated with decreased expansion of IL-10 and TGF-β-producing T cells and the development of a pro-inflammatory Th1 inflammatory response. fg-SiO2 exposure through gastric gavage, but not through food pellets, decreased the frequency of CD103+ dendritic cells. In NOD/DQ8 mice, fg-SiO2 decreased villus-to-crypt ratios, increased IELs counts, and enhanced the Th1 inflammatory response induced by immunization to gluten.
Conclusions: Chronic oral exposure to the food additive SiO2 blocked the establishment of OT in the gut leading to intestinal inflammation and worsening of gluten-induced immunopathology in NOD/DQ8 mice. The results should prompt investigation on the link between SiO2 exposure and food sensitivities in humans.
Background: The incidence of celiac disease (CD) has increased over the last decades, especially in females and children. It’s not clear if this is a true increase or due to the availability of highly sensitive testing and increased awareness. Recent reports suggest that CD incidence reached its peak and starting to plateau in many countries over the world. Our study aims to update the CD incidence trend over the last two decades in a well-defined US population.
Methods: Using the Rochester Epidemiology Project (REP) data, we reviewed the electronic health records of both Mayo Clinic and Olmsted Medical Center between January 01, 2000, and December 31, 2021. We identified all CD patients who were diagnosed during the study periods and resided in Olmsted County. Incidence rates were calculated by age, sex, and calendar year and standardized to the 2020 US population.
Results: We identified a total of 662 patients who were diagnosed with CD during the study period. Of those 182 (27%) were children and 424 (64%) were females. The CD incidence rate was higher at the end of the study period at 16.7 (2000-2002) vs 10.3 (2018-2021) per 100.000 person-year. The overall CD incidence rate peaked at 26.4 per 100.000 person-year between 2009 and 2011 and seems to have plateaued and trended down for adults after 2011 especially patients who were > 65 years at diagnosis. On the other hand, the CD incidence rate continued to increase in children. The CD incidence rate in younger children aged (0-10) years at diagnosis is continuing to increase over the last two decades from 11 (2000-2002) to 30 (2018-2021) per 100.000 person-year. There was no significant difference in incidence trend over the last two decades based on gender although females consistently had higher incidence. Figure1
Conclusion: Even though the overall CD incidence rate seems to be plateauing in Olmsted County. CD incidence rate continues to increase in children, which can reflect a shift to earlier diagnosis, or due to a time-based environmental condition(s), that is losing its effect on older patients but affects children as new arrivals to the risk environment.
Sex Adjusted Incidence Rate of Celiac Disease by Age groups between 2000-2021

Sex Adjusted Incidence Rate of Celiac Disease by Age groups between 2000-2021

INTRODUCTION: Alpha-gal syndrome (AGS) is an immunoglobulin E (IgE) mediated delayed hypersensitivity reaction to galactose-alpha-1,3-galactose (alpha-gal), a carbohydrate on the cells of non-primate mammals. Sensitization is thought to be secondary to ectoparasitic bites, primarily the Lone Star tick endemic to the Southeastern and Eastern United States. Angioedema, anaphylaxis, urticaria, and/or gastrointestinal symptoms occurring 2 to 6 hours following ingestion of non-primate mammalian derived products is the classic presentation. There are reports of a primarily gastrointestinal phenotype of AGS in adults. We sought to determine clinical presentation and response to dietary management of patients with alpha-gal sensitization who presented to a pediatric gastroenterology clinic in an endemic area.
METHODS: We performed a retrospective chart review on patients ages 0-19 from January 1st, 2017, through April 1st, 2022, that were tested for alpha-gal specific IgE (sIgE) at Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, TN. We assessed charts of patients tested through the pediatric gastroenterology clinic to identify demographic data, clinical presentation, and response to elimination diet. Positive alpha-gal was defined as > 0.10 kU/L (Viracor). sIgE for beef, lamb/mutton, and pork (positive > 0.35 kU/L) were reported. Chi-squared and Fisher Exact tests were used for categorical data and Wilcoxon rank-sum test for continuous variables. One way ANOVA was used when comparing response to dietary elimination.
RESULTS: We identified 199 patients who had testing for AGS of which 20.1% (n=40) had a positive alpha-gal sIgE. Positive patients were more likely to be male (67.5% vs 40.9%, p=0.003) and have a known tick exposure (40% vs 11.9%, p<0.001). Positive patients were more likely to have additional symptoms of classic AGS (urticaria, angioedema, etc.) beyond GI symptoms, but 31/40 (77.5%) reported GI symptoms alone. Of 40 patients with positive testing, 30 attempted dietary elimination. Eight (27%) saw complete improvement in their symptoms, 8 (27%) saw partial improvement and 14 (47%) saw no improvement. Patients who improved with dietary elimination were more likely to be male and had a non-significant trend for higher overall specific IgE against alpha-gal, but it was higher sIgE for beef, lamb, and pork that was statistically significant as a predictor of elimination response, compared to those that did not experience improvement.
CONCLUSIONS: In an area endemic for alpha-gal, 20.1% of pediatric patients tested positive for alpha-gal sIgE after evaluation in a pediatric gastroenterology clinic and the majority presented with GI symptoms alone. At least 40% of these patients responded to dietary elimination. Responders were more likely to be male and have higher levels of sIgE for beef, lamb, and pork.
Objectives and Study
The pathogenesis of celiac disease (CD) involves a triad of predisposing genes (HLA DQ2/8), gluten and environmental factors. The environmental factors remain not well defined. Since epigenetic mechanisms operate at the interface between genetic predisposition and environment, the intestinal epithelial cells (IECs), forming a critical barrier to the environment, are the disease-relevant cell type to identify epigenetic alterations involved in the pathogenesis of CD.
Our aims are:
1) To identify genes and pathways epigenetically and transcriptionally altered in IECs from CD patients;
2) Generation of patients-derived intestinal epithelial organoids (IEOs) to demonstrate that CD-associated epigenetic alterations are retained in this in vitro model.
Methods
CD patients in gluten containing diet (GCD) and in gluten-free diet (GFD) have been consecutively enrolled together with a matched cohort of controls suffering from other inflammatory gastrointestinal disorders (IGD) (e.g. inflammatory bowel diseases, gastritis, esophagitis).
IECs, highly purified from intestinal biopsies by using enzyme digestion and magnetic beads sorting for the CD326, have been analyzed for genome-wide DNA methylation patterns and gene expression profiles.
IEOs have been generated from a subset of patients and epigenetic results have been compared with the alterations observed in IECs.
Results
We enrolled 181 patients: 96 CD patients in GCD, 20 CD patients in GFD and 65 controls.
Comparing CD patients in GCD and CD patients in GFD versus controls more than 700 and 200 differentially methylated genes (DMGs) have been found, respectively. DMGs have been ordered by significant p-value and the first 17 DMGs are shared. Among these 17 DMGs the main biological processes affected are related to antigen processing and presentation pathway. In particular: PSMB8, PSMB9, TAP1, TAP2 and TAPBP are involved in antigen processing pathway and MHC class I molecules such as HLA-E, HLA-F and HLA-DPB1 are involved in antigen presentation.
All the genes involved in these pathways have been found hypomethylated and overexpressed in CD.
IEOs have been generated from 5 controls and 5 CD patients. The methylation analysis showed that the DMGs in IELs are retained in IEOs.
Conclusions
The intestinal epithelium of CD patients in GCD or GFD is altered showing antigen processing and presentation pathways constitutively activated only in CD patients and not in patients suffering from other IGD. In IECs from patients with CD high amounts of endogenous peptides (gliadin) are pumped to the endoplasmic reticulum, loaded in MHC class I molecules and transported to the cell surface to be recognized by T-cells.
The environment-induced epigenetic modifications of IECs are retained in IEOs suggesting it is a good in vitro model to further investigate the role of these pathways in the pathogenesis of CD.

Society: AGA


Saturday
Society: AGA

Background: Diet is known to alter the risk of depression. Increasing data also demonstrate a causal role of the gut microbiome in mental illness, via the gut-brain axis. However, it remains unclear how diet and the microbiome mechanistically influence depression risk in humans. Leveraging dietary, metabolomics, microbiome, and depression data, we assessed how gut microbial species and their pathways may mediate the association between depression and citrus, a food group that possibly protects against risk of depression.

Methods: We conducted a prospective study in the Nurses’ Health Study II (NHSII) between 2003 and 2017 among 32,427 middle-aged women free of depression at baseline. Citrus intake was determined using validated food frequency questionnaires collected every 4 years. Depression was defined according to physician-diagnosis and antidepressant use. Between 2013-2014, 207 NHSII participants enrolled in a nested substudy, providing up to 4 stool samples (profiled by shotgun metagenomics) and a blood sample (profiled by LC-MS-based metabolomics). Cox proportional hazard models were used to relate citrus intake with depression risk. Linear mixed effects models were used to relate diet with gut microbial features, and microbial features with depression. We also associated microbial features with a depression-risk score, derived according to levels of circulating serotonin and GABA. All models were adjusted for multiple dietary, medication and lifestyle variables including age, BMI, calorie/alcohol intake, and diet quality. We validated our findings in a subcohort of 307 men in the Health Professionals Follow-up Study (HPFS).

Results: Total citrus intake was associated with a lower risk of incident depression (ptrend 0.001), with a multivariable relative risk of 0.80 (95% CI, 0.68-0.93), comparing extreme quintiles. Within the NHSII substudy, greater citrus intake was associated with increased abundance of Faecalibacterium prausnitzii (β 0.026, FDR 0.17). In turn, levels of F. prausnitzii were higher in non-depressed individuals compared to depressed participants (p 0.003). Greater abundance of F. prausnitzii was also associated with our metabolomics-based depression-risk score in the NHSII (p 0.03), and in the HPFS validation study (p 0.02). In an exploratory analysis of gut microbial pathways, S-Adenosyl-L-Methionine (SAM) cycle I, encoded by F. prausnitzii, was reduced in depressed participants.

Conclusion: Greater citrus intake was prospectively associated with lower risk of depression, and with greater abundance of F. prausnitzii. In turn, participants with depression had lower levels of F. prausnitzii and lower abundance of its genes capable of producing SAM, a compound known to have antidepressant properties. These data offer a potential mechanism by which diet influences the gut microbiome to reduce risk of depression.

Saturday
Society: AGA

Background: Diet is known to alter the risk of depression. Increasing data also demonstrate a causal role of the gut microbiome in mental illness, via the gut-brain axis. However, it remains unclear how diet and the microbiome mechanistically influence depression risk in humans. Leveraging dietary, metabolomics, microbiome, and depression data, we assessed how gut microbial species and their pathways may mediate the association between depression and citrus, a food group that possibly protects against risk of depression.

Methods: We conducted a prospective study in the Nurses’ Health Study II (NHSII) between 2003 and 2017 among 32,427 middle-aged women free of depression at baseline. Citrus intake was determined using validated food frequency questionnaires collected every 4 years. Depression was defined according to physician-diagnosis and antidepressant use. Between 2013-2014, 207 NHSII participants enrolled in a nested substudy, providing up to 4 stool samples (profiled by shotgun metagenomics) and a blood sample (profiled by LC-MS-based metabolomics). Cox proportional hazard models were used to relate citrus intake with depression risk. Linear mixed effects models were used to relate diet with gut microbial features, and microbial features with depression. We also associated microbial features with a depression-risk score, derived according to levels of circulating serotonin and GABA. All models were adjusted for multiple dietary, medication and lifestyle variables including age, BMI, calorie/alcohol intake, and diet quality. We validated our findings in a subcohort of 307 men in the Health Professionals Follow-up Study (HPFS).

Results: Total citrus intake was associated with a lower risk of incident depression (ptrend 0.001), with a multivariable relative risk of 0.80 (95% CI, 0.68-0.93), comparing extreme quintiles. Within the NHSII substudy, greater citrus intake was associated with increased abundance of Faecalibacterium prausnitzii (β 0.026, FDR 0.17). In turn, levels of F. prausnitzii were higher in non-depressed individuals compared to depressed participants (p 0.003). Greater abundance of F. prausnitzii was also associated with our metabolomics-based depression-risk score in the NHSII (p 0.03), and in the HPFS validation study (p 0.02). In an exploratory analysis of gut microbial pathways, S-Adenosyl-L-Methionine (SAM) cycle I, encoded by F. prausnitzii, was reduced in depressed participants.

Conclusion: Greater citrus intake was prospectively associated with lower risk of depression, and with greater abundance of F. prausnitzii. In turn, participants with depression had lower levels of F. prausnitzii and lower abundance of its genes capable of producing SAM, a compound known to have antidepressant properties. These data offer a potential mechanism by which diet influences the gut microbiome to reduce risk of depression.
Background: Experiences of discrimination are associated with adverse health outcomes, including obesity and obesity-related comorbidities. However, the underlying whole-body mechanisms remain unclear. We investigated the impact of discrimination experiences on brain reactivity to food images and associated dysregulations in the brain-gut microbiome (BGM) system. Methods: Brain responses to healthy and unhealthy food cues were obtained by magnetic resonance imaging in 107 male and female participants. Fecal samples were collected to measure fecal metabolites. The Everyday Discrimination Scale was administered to assess perceived experiences of chronic and routine unfair treatment. Structural equation modeling (SEM) was used to evaluate complex relationships between discrimination and altered bidirectional communication within the BGM system in the context of reactivity to food stimuli. Results: Discrimination was associated with increased food-cue reactivity in frontal-striatal regions involved in reward processing, motivation, and executive control, especially for unhealthy foods, as well as altered glutamate-pathway metabolites involved in oxidative stress and inflammation. SEM analyses demonstrated a significant association between discrimination-related brain and gut signatures skewed towards unhealthy foods, after adjusting for key variables such as age, sex, diet, BMI, race and socioeconomic status. Conclusions: Discrimination, as a stressor, may contribute to enhanced food-cue reactivity and BGM system disruptions that can promote unhealthy eating behaviors, leading to increased risk for obesity and related diseases. Treatments that normalize these alterations may benefit individuals with discrimination-related stress exposure.

Saturday
Society: AGA

Background: Diet is known to alter the risk of depression. Increasing data also demonstrate a causal role of the gut microbiome in mental illness, via the gut-brain axis. However, it remains unclear how diet and the microbiome mechanistically influence depression risk in humans. Leveraging dietary, metabolomics, microbiome, and depression data, we assessed how gut microbial species and their pathways may mediate the association between depression and citrus, a food group that possibly protects against risk of depression.

Methods: We conducted a prospective study in the Nurses’ Health Study II (NHSII) between 2003 and 2017 among 32,427 middle-aged women free of depression at baseline. Citrus intake was determined using validated food frequency questionnaires collected every 4 years. Depression was defined according to physician-diagnosis and antidepressant use. Between 2013-2014, 207 NHSII participants enrolled in a nested substudy, providing up to 4 stool samples (profiled by shotgun metagenomics) and a blood sample (profiled by LC-MS-based metabolomics). Cox proportional hazard models were used to relate citrus intake with depression risk. Linear mixed effects models were used to relate diet with gut microbial features, and microbial features with depression. We also associated microbial features with a depression-risk score, derived according to levels of circulating serotonin and GABA. All models were adjusted for multiple dietary, medication and lifestyle variables including age, BMI, calorie/alcohol intake, and diet quality. We validated our findings in a subcohort of 307 men in the Health Professionals Follow-up Study (HPFS).

Results: Total citrus intake was associated with a lower risk of incident depression (ptrend 0.001), with a multivariable relative risk of 0.80 (95% CI, 0.68-0.93), comparing extreme quintiles. Within the NHSII substudy, greater citrus intake was associated with increased abundance of Faecalibacterium prausnitzii (β 0.026, FDR 0.17). In turn, levels of F. prausnitzii were higher in non-depressed individuals compared to depressed participants (p 0.003). Greater abundance of F. prausnitzii was also associated with our metabolomics-based depression-risk score in the NHSII (p 0.03), and in the HPFS validation study (p 0.02). In an exploratory analysis of gut microbial pathways, S-Adenosyl-L-Methionine (SAM) cycle I, encoded by F. prausnitzii, was reduced in depressed participants.

Conclusion: Greater citrus intake was prospectively associated with lower risk of depression, and with greater abundance of F. prausnitzii. In turn, participants with depression had lower levels of F. prausnitzii and lower abundance of its genes capable of producing SAM, a compound known to have antidepressant properties. These data offer a potential mechanism by which diet influences the gut microbiome to reduce risk of depression.
Background: Experiences of discrimination are associated with adverse health outcomes, including obesity and obesity-related comorbidities. However, the underlying whole-body mechanisms remain unclear. We investigated the impact of discrimination experiences on brain reactivity to food images and associated dysregulations in the brain-gut microbiome (BGM) system. Methods: Brain responses to healthy and unhealthy food cues were obtained by magnetic resonance imaging in 107 male and female participants. Fecal samples were collected to measure fecal metabolites. The Everyday Discrimination Scale was administered to assess perceived experiences of chronic and routine unfair treatment. Structural equation modeling (SEM) was used to evaluate complex relationships between discrimination and altered bidirectional communication within the BGM system in the context of reactivity to food stimuli. Results: Discrimination was associated with increased food-cue reactivity in frontal-striatal regions involved in reward processing, motivation, and executive control, especially for unhealthy foods, as well as altered glutamate-pathway metabolites involved in oxidative stress and inflammation. SEM analyses demonstrated a significant association between discrimination-related brain and gut signatures skewed towards unhealthy foods, after adjusting for key variables such as age, sex, diet, BMI, race and socioeconomic status. Conclusions: Discrimination, as a stressor, may contribute to enhanced food-cue reactivity and BGM system disruptions that can promote unhealthy eating behaviors, leading to increased risk for obesity and related diseases. Treatments that normalize these alterations may benefit individuals with discrimination-related stress exposure.
Maternal immune activation (MIA) derived from late gestational infection such as seen in chorioamnionitis poses a significantly increased risk for neurodevelopmental deficits in the offspring. Manipulating early microbiota through maternal probiotics supplementation has been shown to be an effective means to improve outcomes, however, the mechanisms remain unclear. In this study we modeled MIA by maternal lipopolysaccharide (LPS) exposure (i.p. injection at E16) and tested the hypothesis that maternal probiotic administration during lactation may rescue the adverse neurodevelopmental outcome of MIA on offspring through the impact on blood-brain barrier (BBB) development and function. T2W, Time of flight, and T1W MRI with contrast were used to evaluate BBB development and permeability at early postnatal age (two weeks of age). Morris water maze test was used to evaluate long term cognitive function at 12 weeks of age. The effects of MIA with or without maternal Limosilactobacillus reuteri (L. reuteri) exposure on gut microbiome and systemic and brain metabolites were investigated using 16S DNA sequencing of fecal samples and metabonomic analysis at both two and 12 weeks of age. We demonstrated that MIA modeled by exposing pregnant dams to LPS induced an underdevelopment of the blood vessels, an increase in permeability and astrogliosis of BBB at pre-wean age. The BBB developmental and functional deficits early in life impaired spatial learning later in life. Maternal L. reuteri supplementation starting at birth rescued the BBB underdevelopment and dysfunction-associated cognitive function. β-diversity was significantly affected by LPS with or without maternal L. reuteri exposure. We further identified two lipid metabolites that can cross the BBB upon LPS insult and fourteen metabolic products of lipid/bile acid metabolism associated with maternal L. reuteri exposure during lactation that can cross the BBB. We conclude that maternal L. reuteri-mediated alterations in β-diversity of the microbial community and metabolic responses in the offspring provide mechanisms and potential targets for promoting BBB integrity and long-term neurodevelopmental outcomes.

Saturday
Society: AGA

Background: Diet is known to alter the risk of depression. Increasing data also demonstrate a causal role of the gut microbiome in mental illness, via the gut-brain axis. However, it remains unclear how diet and the microbiome mechanistically influence depression risk in humans. Leveraging dietary, metabolomics, microbiome, and depression data, we assessed how gut microbial species and their pathways may mediate the association between depression and citrus, a food group that possibly protects against risk of depression.

Methods: We conducted a prospective study in the Nurses’ Health Study II (NHSII) between 2003 and 2017 among 32,427 middle-aged women free of depression at baseline. Citrus intake was determined using validated food frequency questionnaires collected every 4 years. Depression was defined according to physician-diagnosis and antidepressant use. Between 2013-2014, 207 NHSII participants enrolled in a nested substudy, providing up to 4 stool samples (profiled by shotgun metagenomics) and a blood sample (profiled by LC-MS-based metabolomics). Cox proportional hazard models were used to relate citrus intake with depression risk. Linear mixed effects models were used to relate diet with gut microbial features, and microbial features with depression. We also associated microbial features with a depression-risk score, derived according to levels of circulating serotonin and GABA. All models were adjusted for multiple dietary, medication and lifestyle variables including age, BMI, calorie/alcohol intake, and diet quality. We validated our findings in a subcohort of 307 men in the Health Professionals Follow-up Study (HPFS).

Results: Total citrus intake was associated with a lower risk of incident depression (ptrend 0.001), with a multivariable relative risk of 0.80 (95% CI, 0.68-0.93), comparing extreme quintiles. Within the NHSII substudy, greater citrus intake was associated with increased abundance of Faecalibacterium prausnitzii (β 0.026, FDR 0.17). In turn, levels of F. prausnitzii were higher in non-depressed individuals compared to depressed participants (p 0.003). Greater abundance of F. prausnitzii was also associated with our metabolomics-based depression-risk score in the NHSII (p 0.03), and in the HPFS validation study (p 0.02). In an exploratory analysis of gut microbial pathways, S-Adenosyl-L-Methionine (SAM) cycle I, encoded by F. prausnitzii, was reduced in depressed participants.

Conclusion: Greater citrus intake was prospectively associated with lower risk of depression, and with greater abundance of F. prausnitzii. In turn, participants with depression had lower levels of F. prausnitzii and lower abundance of its genes capable of producing SAM, a compound known to have antidepressant properties. These data offer a potential mechanism by which diet influences the gut microbiome to reduce risk of depression.
Background: Experiences of discrimination are associated with adverse health outcomes, including obesity and obesity-related comorbidities. However, the underlying whole-body mechanisms remain unclear. We investigated the impact of discrimination experiences on brain reactivity to food images and associated dysregulations in the brain-gut microbiome (BGM) system. Methods: Brain responses to healthy and unhealthy food cues were obtained by magnetic resonance imaging in 107 male and female participants. Fecal samples were collected to measure fecal metabolites. The Everyday Discrimination Scale was administered to assess perceived experiences of chronic and routine unfair treatment. Structural equation modeling (SEM) was used to evaluate complex relationships between discrimination and altered bidirectional communication within the BGM system in the context of reactivity to food stimuli. Results: Discrimination was associated with increased food-cue reactivity in frontal-striatal regions involved in reward processing, motivation, and executive control, especially for unhealthy foods, as well as altered glutamate-pathway metabolites involved in oxidative stress and inflammation. SEM analyses demonstrated a significant association between discrimination-related brain and gut signatures skewed towards unhealthy foods, after adjusting for key variables such as age, sex, diet, BMI, race and socioeconomic status. Conclusions: Discrimination, as a stressor, may contribute to enhanced food-cue reactivity and BGM system disruptions that can promote unhealthy eating behaviors, leading to increased risk for obesity and related diseases. Treatments that normalize these alterations may benefit individuals with discrimination-related stress exposure.
Maternal immune activation (MIA) derived from late gestational infection such as seen in chorioamnionitis poses a significantly increased risk for neurodevelopmental deficits in the offspring. Manipulating early microbiota through maternal probiotics supplementation has been shown to be an effective means to improve outcomes, however, the mechanisms remain unclear. In this study we modeled MIA by maternal lipopolysaccharide (LPS) exposure (i.p. injection at E16) and tested the hypothesis that maternal probiotic administration during lactation may rescue the adverse neurodevelopmental outcome of MIA on offspring through the impact on blood-brain barrier (BBB) development and function. T2W, Time of flight, and T1W MRI with contrast were used to evaluate BBB development and permeability at early postnatal age (two weeks of age). Morris water maze test was used to evaluate long term cognitive function at 12 weeks of age. The effects of MIA with or without maternal Limosilactobacillus reuteri (L. reuteri) exposure on gut microbiome and systemic and brain metabolites were investigated using 16S DNA sequencing of fecal samples and metabonomic analysis at both two and 12 weeks of age. We demonstrated that MIA modeled by exposing pregnant dams to LPS induced an underdevelopment of the blood vessels, an increase in permeability and astrogliosis of BBB at pre-wean age. The BBB developmental and functional deficits early in life impaired spatial learning later in life. Maternal L. reuteri supplementation starting at birth rescued the BBB underdevelopment and dysfunction-associated cognitive function. β-diversity was significantly affected by LPS with or without maternal L. reuteri exposure. We further identified two lipid metabolites that can cross the BBB upon LPS insult and fourteen metabolic products of lipid/bile acid metabolism associated with maternal L. reuteri exposure during lactation that can cross the BBB. We conclude that maternal L. reuteri-mediated alterations in β-diversity of the microbial community and metabolic responses in the offspring provide mechanisms and potential targets for promoting BBB integrity and long-term neurodevelopmental outcomes.
Introduction. Several evidence highlights the relevance of microbiota gut-brain axis (MGB) in brain diseases, including Alzheimer's disease (AD). Indeed, AD patients display gut dysbiosis, altered intestinal barrier and enteric neurogenic/inflammatory responses that, besides bowel symptoms, contribute to brain pathology. In this context, the modulation of gut microbiota is emerging as a suitable additional therapeutical option, to target MGB, and to halt or slow down central pathology. This study examined the effects of LACTIPLANTIBACILLUS PLANTARUM (HEAL9), in a spontaneous model of AD.
Methods. Senescence-accelerated mouse prone 8 (SAMP8) mice (4 months old) were employed as a model that develops spontaneously AD and SAMR1 mice as controls. Mice were treated orally with HEAL9 1X109 CFU/mouse/day or placebo for two months (n=6/group) to evaluate the effects of probiotic during the early stages of AD before the full development of brain pathology. Mice underwent Morris water maze test. Then, after assessment of fecal output over one hour, animals were sacrificed, and colonic longitudinal muscle preparations were set up in organ baths and connected to isometric transducers. Neurogenic motor responses were evoked by electrical stimulation (10 Hz) in standard Krebs solution or containing guanethidine (10 μM), L-NAME (100 μM) and NK1, NK2 and NK3 receptor antagonists (10 μM) to record cholinergic contractions. Carbachol (1 μM)-induced myogenic contractions in the presence of tetrodotoxin (1 μM) were also recorded. Plasma and brain and colonic tissues were excised and processed for the evaluation of: 1) β-amyloid (Aβ)1-42 and interleukin-(IL)-1β levels (ELISA); 2) gut barrier alterations (immunofluorescence of claudin-1 tight junction, lipopolysaccharide-binding protein (LBP) levels by ELISA).
Results. SAMP8 mice displayed: 1) cognitive dysfunctions; 2) impaired colonic transit and in vitro contractility, characterized by an altered cholinergic neurotransmission; 3) increased colonic and brain Aβ1-42, IL-1β and plasma LBP levels; 4) altered distribution and decreased expression of colonic claudin-1; 5) altered mucus layer. Intake of HEAL9 counteracted cognitive impairment, colonic motor dysfunctions and decreased brain and colonic Aβ1-42 and IL-1β and plasma LBP levels. HEAL9 also restored colonic claudin-1 expression and distribution.
Conclusions. HEAL9 exerts beneficial effects on AD, by counteracting central and enteric AD-related protein deposition and inflammation and preserving gut barrier integrity. HEAL9 also restored colonic motility through the recovery of cholinergic excitatory neurogenic motility. These results substantiate the concept that the modulation of gut microbiota can represent a suitable additional therapeutical strategy, to target the MGB and to alleviate AD and related intestinal symptoms.

Saturday
Society: AGA

Background: Diet is known to alter the risk of depression. Increasing data also demonstrate a causal role of the gut microbiome in mental illness, via the gut-brain axis. However, it remains unclear how diet and the microbiome mechanistically influence depression risk in humans. Leveraging dietary, metabolomics, microbiome, and depression data, we assessed how gut microbial species and their pathways may mediate the association between depression and citrus, a food group that possibly protects against risk of depression.

Methods: We conducted a prospective study in the Nurses’ Health Study II (NHSII) between 2003 and 2017 among 32,427 middle-aged women free of depression at baseline. Citrus intake was determined using validated food frequency questionnaires collected every 4 years. Depression was defined according to physician-diagnosis and antidepressant use. Between 2013-2014, 207 NHSII participants enrolled in a nested substudy, providing up to 4 stool samples (profiled by shotgun metagenomics) and a blood sample (profiled by LC-MS-based metabolomics). Cox proportional hazard models were used to relate citrus intake with depression risk. Linear mixed effects models were used to relate diet with gut microbial features, and microbial features with depression. We also associated microbial features with a depression-risk score, derived according to levels of circulating serotonin and GABA. All models were adjusted for multiple dietary, medication and lifestyle variables including age, BMI, calorie/alcohol intake, and diet quality. We validated our findings in a subcohort of 307 men in the Health Professionals Follow-up Study (HPFS).

Results: Total citrus intake was associated with a lower risk of incident depression (ptrend 0.001), with a multivariable relative risk of 0.80 (95% CI, 0.68-0.93), comparing extreme quintiles. Within the NHSII substudy, greater citrus intake was associated with increased abundance of Faecalibacterium prausnitzii (β 0.026, FDR 0.17). In turn, levels of F. prausnitzii were higher in non-depressed individuals compared to depressed participants (p 0.003). Greater abundance of F. prausnitzii was also associated with our metabolomics-based depression-risk score in the NHSII (p 0.03), and in the HPFS validation study (p 0.02). In an exploratory analysis of gut microbial pathways, S-Adenosyl-L-Methionine (SAM) cycle I, encoded by F. prausnitzii, was reduced in depressed participants.

Conclusion: Greater citrus intake was prospectively associated with lower risk of depression, and with greater abundance of F. prausnitzii. In turn, participants with depression had lower levels of F. prausnitzii and lower abundance of its genes capable of producing SAM, a compound known to have antidepressant properties. These data offer a potential mechanism by which diet influences the gut microbiome to reduce risk of depression.
Background: Experiences of discrimination are associated with adverse health outcomes, including obesity and obesity-related comorbidities. However, the underlying whole-body mechanisms remain unclear. We investigated the impact of discrimination experiences on brain reactivity to food images and associated dysregulations in the brain-gut microbiome (BGM) system. Methods: Brain responses to healthy and unhealthy food cues were obtained by magnetic resonance imaging in 107 male and female participants. Fecal samples were collected to measure fecal metabolites. The Everyday Discrimination Scale was administered to assess perceived experiences of chronic and routine unfair treatment. Structural equation modeling (SEM) was used to evaluate complex relationships between discrimination and altered bidirectional communication within the BGM system in the context of reactivity to food stimuli. Results: Discrimination was associated with increased food-cue reactivity in frontal-striatal regions involved in reward processing, motivation, and executive control, especially for unhealthy foods, as well as altered glutamate-pathway metabolites involved in oxidative stress and inflammation. SEM analyses demonstrated a significant association between discrimination-related brain and gut signatures skewed towards unhealthy foods, after adjusting for key variables such as age, sex, diet, BMI, race and socioeconomic status. Conclusions: Discrimination, as a stressor, may contribute to enhanced food-cue reactivity and BGM system disruptions that can promote unhealthy eating behaviors, leading to increased risk for obesity and related diseases. Treatments that normalize these alterations may benefit individuals with discrimination-related stress exposure.
Maternal immune activation (MIA) derived from late gestational infection such as seen in chorioamnionitis poses a significantly increased risk for neurodevelopmental deficits in the offspring. Manipulating early microbiota through maternal probiotics supplementation has been shown to be an effective means to improve outcomes, however, the mechanisms remain unclear. In this study we modeled MIA by maternal lipopolysaccharide (LPS) exposure (i.p. injection at E16) and tested the hypothesis that maternal probiotic administration during lactation may rescue the adverse neurodevelopmental outcome of MIA on offspring through the impact on blood-brain barrier (BBB) development and function. T2W, Time of flight, and T1W MRI with contrast were used to evaluate BBB development and permeability at early postnatal age (two weeks of age). Morris water maze test was used to evaluate long term cognitive function at 12 weeks of age. The effects of MIA with or without maternal Limosilactobacillus reuteri (L. reuteri) exposure on gut microbiome and systemic and brain metabolites were investigated using 16S DNA sequencing of fecal samples and metabonomic analysis at both two and 12 weeks of age. We demonstrated that MIA modeled by exposing pregnant dams to LPS induced an underdevelopment of the blood vessels, an increase in permeability and astrogliosis of BBB at pre-wean age. The BBB developmental and functional deficits early in life impaired spatial learning later in life. Maternal L. reuteri supplementation starting at birth rescued the BBB underdevelopment and dysfunction-associated cognitive function. β-diversity was significantly affected by LPS with or without maternal L. reuteri exposure. We further identified two lipid metabolites that can cross the BBB upon LPS insult and fourteen metabolic products of lipid/bile acid metabolism associated with maternal L. reuteri exposure during lactation that can cross the BBB. We conclude that maternal L. reuteri-mediated alterations in β-diversity of the microbial community and metabolic responses in the offspring provide mechanisms and potential targets for promoting BBB integrity and long-term neurodevelopmental outcomes.
Introduction. Several evidence highlights the relevance of microbiota gut-brain axis (MGB) in brain diseases, including Alzheimer's disease (AD). Indeed, AD patients display gut dysbiosis, altered intestinal barrier and enteric neurogenic/inflammatory responses that, besides bowel symptoms, contribute to brain pathology. In this context, the modulation of gut microbiota is emerging as a suitable additional therapeutical option, to target MGB, and to halt or slow down central pathology. This study examined the effects of LACTIPLANTIBACILLUS PLANTARUM (HEAL9), in a spontaneous model of AD.
Methods. Senescence-accelerated mouse prone 8 (SAMP8) mice (4 months old) were employed as a model that develops spontaneously AD and SAMR1 mice as controls. Mice were treated orally with HEAL9 1X109 CFU/mouse/day or placebo for two months (n=6/group) to evaluate the effects of probiotic during the early stages of AD before the full development of brain pathology. Mice underwent Morris water maze test. Then, after assessment of fecal output over one hour, animals were sacrificed, and colonic longitudinal muscle preparations were set up in organ baths and connected to isometric transducers. Neurogenic motor responses were evoked by electrical stimulation (10 Hz) in standard Krebs solution or containing guanethidine (10 μM), L-NAME (100 μM) and NK1, NK2 and NK3 receptor antagonists (10 μM) to record cholinergic contractions. Carbachol (1 μM)-induced myogenic contractions in the presence of tetrodotoxin (1 μM) were also recorded. Plasma and brain and colonic tissues were excised and processed for the evaluation of: 1) β-amyloid (Aβ)1-42 and interleukin-(IL)-1β levels (ELISA); 2) gut barrier alterations (immunofluorescence of claudin-1 tight junction, lipopolysaccharide-binding protein (LBP) levels by ELISA).
Results. SAMP8 mice displayed: 1) cognitive dysfunctions; 2) impaired colonic transit and in vitro contractility, characterized by an altered cholinergic neurotransmission; 3) increased colonic and brain Aβ1-42, IL-1β and plasma LBP levels; 4) altered distribution and decreased expression of colonic claudin-1; 5) altered mucus layer. Intake of HEAL9 counteracted cognitive impairment, colonic motor dysfunctions and decreased brain and colonic Aβ1-42 and IL-1β and plasma LBP levels. HEAL9 also restored colonic claudin-1 expression and distribution.
Conclusions. HEAL9 exerts beneficial effects on AD, by counteracting central and enteric AD-related protein deposition and inflammation and preserving gut barrier integrity. HEAL9 also restored colonic motility through the recovery of cholinergic excitatory neurogenic motility. These results substantiate the concept that the modulation of gut microbiota can represent a suitable additional therapeutical strategy, to target the MGB and to alleviate AD and related intestinal symptoms.
Post-traumatic stress disorder (PTSD) is a mental health disorder triggered by traumatic event/s causing psychiatric and medical morbidities, as well as psychosocial distress. The neurotransmitter serotonin (5-HT) is well-recognized for regulating behavior and emotion. Dysregulation is associated with depression, anxiety, aggression, impulsivity, and suicidal behaviors, all frequently seen in PTSD. 5-HT is synthesized by tryptophan hydroxylase (TPH), acts on 5-HT receptors, and subsequently is deactivated by internalization of 5-HT via the serotonin transporter (SLC6A4, SERT). SSRIs, which target SERT, are commonly used for mood and anxiety disorders, and are the only FDA approved drugs for PTSD. However, the response rate is variable depending upon sex, genetic factors, and environmental factors. 5-HT is abundantly present and synthesized in the gut and alters microbial composition. However, the contribution of intestinal 5-HT and SERT in the progression of PTSD is not understood. Here, we investigated the role of intestinal SERT and its effect on the gut microbiota in the progression of PTSD in a sex-dependent manner. Methods: SERTfl/flxVillin-CreERT2mice (M/F, 8-12 wks) were injected with tamoxifen to induce SERT overexpression in only intestinal epithelial cells (SERT O/EIEC), or corn oil (WT). PTSD mouse model of protracted social isolation (SI) was used as a chronic stressor to elicit aggression in resident-intruder assays. Aggression was measured by the number of attacks, duration of attacks, and onset of attacks. Intestinal mucosa, cecal contents, and brain were collected. Results showed an important role of IEC specific SERT in differentially modulating PTSD-like behavior (aggression) in males and females as evidenced by an increased aggression in isolated SERT O/EIEC males and decreased aggression in SERT O/EIEC single-housed females vs. their respective controls. Reduction in aggression in SERT O/EIEC SI females was concomitant with i) an increase in BDNF and 5a reductase mRNA in amygdala & hippocampus; ii) an increase in ileal MCT10 (SLC16A10, Trp/Phe transporter); iii) increase in Tph-1, a known target of microbiota; iv) an increase in antimicrobial peptides, while isolatedSERT O/EIEC males showed decreases in these pathways. To fully understand the mechanisms underlying these differential responses, we analyzed gut microbiota composition. Pearson correlation analysis in WT and SERT O/EIEC(M/F) showed that gut microbial species from the order-Bacteroidales, Gastranaerophilales, and genus-Anaerotruncus positively correlated with aggression and Desulfovibrio was negatively correlated. Conclusion: These novel data suggest that aggression due to social isolation is modulated by the gut microbiota in a sex-dependent manner via mechanisms involving intestinal serotonergic machinery.

Saturday
Society: AGA

Background: Diet is known to alter the risk of depression. Increasing data also demonstrate a causal role of the gut microbiome in mental illness, via the gut-brain axis. However, it remains unclear how diet and the microbiome mechanistically influence depression risk in humans. Leveraging dietary, metabolomics, microbiome, and depression data, we assessed how gut microbial species and their pathways may mediate the association between depression and citrus, a food group that possibly protects against risk of depression.

Methods: We conducted a prospective study in the Nurses’ Health Study II (NHSII) between 2003 and 2017 among 32,427 middle-aged women free of depression at baseline. Citrus intake was determined using validated food frequency questionnaires collected every 4 years. Depression was defined according to physician-diagnosis and antidepressant use. Between 2013-2014, 207 NHSII participants enrolled in a nested substudy, providing up to 4 stool samples (profiled by shotgun metagenomics) and a blood sample (profiled by LC-MS-based metabolomics). Cox proportional hazard models were used to relate citrus intake with depression risk. Linear mixed effects models were used to relate diet with gut microbial features, and microbial features with depression. We also associated microbial features with a depression-risk score, derived according to levels of circulating serotonin and GABA. All models were adjusted for multiple dietary, medication and lifestyle variables including age, BMI, calorie/alcohol intake, and diet quality. We validated our findings in a subcohort of 307 men in the Health Professionals Follow-up Study (HPFS).

Results: Total citrus intake was associated with a lower risk of incident depression (ptrend 0.001), with a multivariable relative risk of 0.80 (95% CI, 0.68-0.93), comparing extreme quintiles. Within the NHSII substudy, greater citrus intake was associated with increased abundance of Faecalibacterium prausnitzii (β 0.026, FDR 0.17). In turn, levels of F. prausnitzii were higher in non-depressed individuals compared to depressed participants (p 0.003). Greater abundance of F. prausnitzii was also associated with our metabolomics-based depression-risk score in the NHSII (p 0.03), and in the HPFS validation study (p 0.02). In an exploratory analysis of gut microbial pathways, S-Adenosyl-L-Methionine (SAM) cycle I, encoded by F. prausnitzii, was reduced in depressed participants.

Conclusion: Greater citrus intake was prospectively associated with lower risk of depression, and with greater abundance of F. prausnitzii. In turn, participants with depression had lower levels of F. prausnitzii and lower abundance of its genes capable of producing SAM, a compound known to have antidepressant properties. These data offer a potential mechanism by which diet influences the gut microbiome to reduce risk of depression.
Background: Experiences of discrimination are associated with adverse health outcomes, including obesity and obesity-related comorbidities. However, the underlying whole-body mechanisms remain unclear. We investigated the impact of discrimination experiences on brain reactivity to food images and associated dysregulations in the brain-gut microbiome (BGM) system. Methods: Brain responses to healthy and unhealthy food cues were obtained by magnetic resonance imaging in 107 male and female participants. Fecal samples were collected to measure fecal metabolites. The Everyday Discrimination Scale was administered to assess perceived experiences of chronic and routine unfair treatment. Structural equation modeling (SEM) was used to evaluate complex relationships between discrimination and altered bidirectional communication within the BGM system in the context of reactivity to food stimuli. Results: Discrimination was associated with increased food-cue reactivity in frontal-striatal regions involved in reward processing, motivation, and executive control, especially for unhealthy foods, as well as altered glutamate-pathway metabolites involved in oxidative stress and inflammation. SEM analyses demonstrated a significant association between discrimination-related brain and gut signatures skewed towards unhealthy foods, after adjusting for key variables such as age, sex, diet, BMI, race and socioeconomic status. Conclusions: Discrimination, as a stressor, may contribute to enhanced food-cue reactivity and BGM system disruptions that can promote unhealthy eating behaviors, leading to increased risk for obesity and related diseases. Treatments that normalize these alterations may benefit individuals with discrimination-related stress exposure.
Maternal immune activation (MIA) derived from late gestational infection such as seen in chorioamnionitis poses a significantly increased risk for neurodevelopmental deficits in the offspring. Manipulating early microbiota through maternal probiotics supplementation has been shown to be an effective means to improve outcomes, however, the mechanisms remain unclear. In this study we modeled MIA by maternal lipopolysaccharide (LPS) exposure (i.p. injection at E16) and tested the hypothesis that maternal probiotic administration during lactation may rescue the adverse neurodevelopmental outcome of MIA on offspring through the impact on blood-brain barrier (BBB) development and function. T2W, Time of flight, and T1W MRI with contrast were used to evaluate BBB development and permeability at early postnatal age (two weeks of age). Morris water maze test was used to evaluate long term cognitive function at 12 weeks of age. The effects of MIA with or without maternal Limosilactobacillus reuteri (L. reuteri) exposure on gut microbiome and systemic and brain metabolites were investigated using 16S DNA sequencing of fecal samples and metabonomic analysis at both two and 12 weeks of age. We demonstrated that MIA modeled by exposing pregnant dams to LPS induced an underdevelopment of the blood vessels, an increase in permeability and astrogliosis of BBB at pre-wean age. The BBB developmental and functional deficits early in life impaired spatial learning later in life. Maternal L. reuteri supplementation starting at birth rescued the BBB underdevelopment and dysfunction-associated cognitive function. β-diversity was significantly affected by LPS with or without maternal L. reuteri exposure. We further identified two lipid metabolites that can cross the BBB upon LPS insult and fourteen metabolic products of lipid/bile acid metabolism associated with maternal L. reuteri exposure during lactation that can cross the BBB. We conclude that maternal L. reuteri-mediated alterations in β-diversity of the microbial community and metabolic responses in the offspring provide mechanisms and potential targets for promoting BBB integrity and long-term neurodevelopmental outcomes.
Introduction. Several evidence highlights the relevance of microbiota gut-brain axis (MGB) in brain diseases, including Alzheimer's disease (AD). Indeed, AD patients display gut dysbiosis, altered intestinal barrier and enteric neurogenic/inflammatory responses that, besides bowel symptoms, contribute to brain pathology. In this context, the modulation of gut microbiota is emerging as a suitable additional therapeutical option, to target MGB, and to halt or slow down central pathology. This study examined the effects of LACTIPLANTIBACILLUS PLANTARUM (HEAL9), in a spontaneous model of AD.
Methods. Senescence-accelerated mouse prone 8 (SAMP8) mice (4 months old) were employed as a model that develops spontaneously AD and SAMR1 mice as controls. Mice were treated orally with HEAL9 1X109 CFU/mouse/day or placebo for two months (n=6/group) to evaluate the effects of probiotic during the early stages of AD before the full development of brain pathology. Mice underwent Morris water maze test. Then, after assessment of fecal output over one hour, animals were sacrificed, and colonic longitudinal muscle preparations were set up in organ baths and connected to isometric transducers. Neurogenic motor responses were evoked by electrical stimulation (10 Hz) in standard Krebs solution or containing guanethidine (10 μM), L-NAME (100 μM) and NK1, NK2 and NK3 receptor antagonists (10 μM) to record cholinergic contractions. Carbachol (1 μM)-induced myogenic contractions in the presence of tetrodotoxin (1 μM) were also recorded. Plasma and brain and colonic tissues were excised and processed for the evaluation of: 1) β-amyloid (Aβ)1-42 and interleukin-(IL)-1β levels (ELISA); 2) gut barrier alterations (immunofluorescence of claudin-1 tight junction, lipopolysaccharide-binding protein (LBP) levels by ELISA).
Results. SAMP8 mice displayed: 1) cognitive dysfunctions; 2) impaired colonic transit and in vitro contractility, characterized by an altered cholinergic neurotransmission; 3) increased colonic and brain Aβ1-42, IL-1β and plasma LBP levels; 4) altered distribution and decreased expression of colonic claudin-1; 5) altered mucus layer. Intake of HEAL9 counteracted cognitive impairment, colonic motor dysfunctions and decreased brain and colonic Aβ1-42 and IL-1β and plasma LBP levels. HEAL9 also restored colonic claudin-1 expression and distribution.
Conclusions. HEAL9 exerts beneficial effects on AD, by counteracting central and enteric AD-related protein deposition and inflammation and preserving gut barrier integrity. HEAL9 also restored colonic motility through the recovery of cholinergic excitatory neurogenic motility. These results substantiate the concept that the modulation of gut microbiota can represent a suitable additional therapeutical strategy, to target the MGB and to alleviate AD and related intestinal symptoms.
Post-traumatic stress disorder (PTSD) is a mental health disorder triggered by traumatic event/s causing psychiatric and medical morbidities, as well as psychosocial distress. The neurotransmitter serotonin (5-HT) is well-recognized for regulating behavior and emotion. Dysregulation is associated with depression, anxiety, aggression, impulsivity, and suicidal behaviors, all frequently seen in PTSD. 5-HT is synthesized by tryptophan hydroxylase (TPH), acts on 5-HT receptors, and subsequently is deactivated by internalization of 5-HT via the serotonin transporter (SLC6A4, SERT). SSRIs, which target SERT, are commonly used for mood and anxiety disorders, and are the only FDA approved drugs for PTSD. However, the response rate is variable depending upon sex, genetic factors, and environmental factors. 5-HT is abundantly present and synthesized in the gut and alters microbial composition. However, the contribution of intestinal 5-HT and SERT in the progression of PTSD is not understood. Here, we investigated the role of intestinal SERT and its effect on the gut microbiota in the progression of PTSD in a sex-dependent manner. Methods: SERTfl/flxVillin-CreERT2mice (M/F, 8-12 wks) were injected with tamoxifen to induce SERT overexpression in only intestinal epithelial cells (SERT O/EIEC), or corn oil (WT). PTSD mouse model of protracted social isolation (SI) was used as a chronic stressor to elicit aggression in resident-intruder assays. Aggression was measured by the number of attacks, duration of attacks, and onset of attacks. Intestinal mucosa, cecal contents, and brain were collected. Results showed an important role of IEC specific SERT in differentially modulating PTSD-like behavior (aggression) in males and females as evidenced by an increased aggression in isolated SERT O/EIEC males and decreased aggression in SERT O/EIEC single-housed females vs. their respective controls. Reduction in aggression in SERT O/EIEC SI females was concomitant with i) an increase in BDNF and 5a reductase mRNA in amygdala & hippocampus; ii) an increase in ileal MCT10 (SLC16A10, Trp/Phe transporter); iii) increase in Tph-1, a known target of microbiota; iv) an increase in antimicrobial peptides, while isolatedSERT O/EIEC males showed decreases in these pathways. To fully understand the mechanisms underlying these differential responses, we analyzed gut microbiota composition. Pearson correlation analysis in WT and SERT O/EIEC(M/F) showed that gut microbial species from the order-Bacteroidales, Gastranaerophilales, and genus-Anaerotruncus positively correlated with aggression and Desulfovibrio was negatively correlated. Conclusion: These novel data suggest that aggression due to social isolation is modulated by the gut microbiota in a sex-dependent manner via mechanisms involving intestinal serotonergic machinery.
Background:
Intestinal microbial dysbiosis is now recognized as a hallmark of Parkinson’s disease (PD). Our group and others have shown that PD dysbiosis is characterized by increased pro-inflammatory bacteria and reduced abundance of short-chain fatty acid (SCFA)-producing bacteria. SCFAs stimulate enteroendocrine L-cells to secrete glucagon-like peptide-1 (GLP-1), an incretin hormone with neuroprotective properties and protective effects on the intestinal barrier. Here we hypothesize that PD dysbiosis is associated with decreased SCFAs, decreased L-cells, reduced GLP-1 secretion, and intestinal barrier dysfunction, findings that may be reversed by SCFA-promoting prebiotic therapy.

Methods:
We assembled a cohort of 19 PD patients and their spousal controls who provided stool and serum from which we measured SCFA (butyrate, propionate, and acetate) levels by GC-MS. Serum GLP-1 (45 min after consumption of a standard meal), fecal calprotectin, and serum zonulin (marker of intestinal barrier integrity) were measured by ELISA. Outcomes were reassessed after consumption of 10g of prebiotic fiber designed to increase SCFA-producing gut bacteria twice daily for 10 days and analyzed by Wilcoxon-signed rank test for pairwise comparisons. To determine L-cell density from patient-specific crypts, apical-out sigmoid colonoids and ileal enteroids were derived from 14 PD and control subjects, embedded in extracellular protein matrix, and treated with growth factors to expand Lgr5+ stem cells; L-cells were identified immunohistochemically by antibodies to chromogranin and GLP-1.

Results:
Here we demonstrate that compared to healthy control subjects, PD patients contain decreased SCFAs, particularly butyrate, in stool and plasma (p<0.01), corresponding to significantly decreased abundance of intestinal SCFA-producing bacteria such as Bifidobacterium as well as a 2-fold reduction in postprandial GLP-1 secretion (p=0.02) that we previously noted. PD-derived colonic and ileal organoids produce fewer L-cells than healthy organoids (trend). Furthermore, we show significantly increased calprotectin (p=0.044) and decreased intestinal barrier integrity (p<0.001) in PD patients. Our preliminary data show that prebiotic supplementation may restore plasma SCFAs, reduce fecal calprotectin, and improve intestinal barrier integrity.

Conclusions:
Intestinal dysbiosis in PD is associated with decreased 1) abundance of SCFA-producing bacteria, 2) serum and stool SCFAs, 3) GLP-1 secretion, and 4) intestinal barrier integrity, as well as increased fecal calprotectin. Preliminary data suggest these effects can be mitigated by prebiotic supplementation. These findings may hold important implications for impaired neuroprotection (GLP-1) and gut inflammation (barrier integrity and calprotectin) in PD. Future studies will determine the effects of prebiotics on clinical outcomes.

Saturday
Society: AGA

Background: Diet is known to alter the risk of depression. Increasing data also demonstrate a causal role of the gut microbiome in mental illness, via the gut-brain axis. However, it remains unclear how diet and the microbiome mechanistically influence depression risk in humans. Leveraging dietary, metabolomics, microbiome, and depression data, we assessed how gut microbial species and their pathways may mediate the association between depression and citrus, a food group that possibly protects against risk of depression.

Methods: We conducted a prospective study in the Nurses’ Health Study II (NHSII) between 2003 and 2017 among 32,427 middle-aged women free of depression at baseline. Citrus intake was determined using validated food frequency questionnaires collected every 4 years. Depression was defined according to physician-diagnosis and antidepressant use. Between 2013-2014, 207 NHSII participants enrolled in a nested substudy, providing up to 4 stool samples (profiled by shotgun metagenomics) and a blood sample (profiled by LC-MS-based metabolomics). Cox proportional hazard models were used to relate citrus intake with depression risk. Linear mixed effects models were used to relate diet with gut microbial features, and microbial features with depression. We also associated microbial features with a depression-risk score, derived according to levels of circulating serotonin and GABA. All models were adjusted for multiple dietary, medication and lifestyle variables including age, BMI, calorie/alcohol intake, and diet quality. We validated our findings in a subcohort of 307 men in the Health Professionals Follow-up Study (HPFS).

Results: Total citrus intake was associated with a lower risk of incident depression (ptrend 0.001), with a multivariable relative risk of 0.80 (95% CI, 0.68-0.93), comparing extreme quintiles. Within the NHSII substudy, greater citrus intake was associated with increased abundance of Faecalibacterium prausnitzii (β 0.026, FDR 0.17). In turn, levels of F. prausnitzii were higher in non-depressed individuals compared to depressed participants (p 0.003). Greater abundance of F. prausnitzii was also associated with our metabolomics-based depression-risk score in the NHSII (p 0.03), and in the HPFS validation study (p 0.02). In an exploratory analysis of gut microbial pathways, S-Adenosyl-L-Methionine (SAM) cycle I, encoded by F. prausnitzii, was reduced in depressed participants.

Conclusion: Greater citrus intake was prospectively associated with lower risk of depression, and with greater abundance of F. prausnitzii. In turn, participants with depression had lower levels of F. prausnitzii and lower abundance of its genes capable of producing SAM, a compound known to have antidepressant properties. These data offer a potential mechanism by which diet influences the gut microbiome to reduce risk of depression.
Background: Experiences of discrimination are associated with adverse health outcomes, including obesity and obesity-related comorbidities. However, the underlying whole-body mechanisms remain unclear. We investigated the impact of discrimination experiences on brain reactivity to food images and associated dysregulations in the brain-gut microbiome (BGM) system. Methods: Brain responses to healthy and unhealthy food cues were obtained by magnetic resonance imaging in 107 male and female participants. Fecal samples were collected to measure fecal metabolites. The Everyday Discrimination Scale was administered to assess perceived experiences of chronic and routine unfair treatment. Structural equation modeling (SEM) was used to evaluate complex relationships between discrimination and altered bidirectional communication within the BGM system in the context of reactivity to food stimuli. Results: Discrimination was associated with increased food-cue reactivity in frontal-striatal regions involved in reward processing, motivation, and executive control, especially for unhealthy foods, as well as altered glutamate-pathway metabolites involved in oxidative stress and inflammation. SEM analyses demonstrated a significant association between discrimination-related brain and gut signatures skewed towards unhealthy foods, after adjusting for key variables such as age, sex, diet, BMI, race and socioeconomic status. Conclusions: Discrimination, as a stressor, may contribute to enhanced food-cue reactivity and BGM system disruptions that can promote unhealthy eating behaviors, leading to increased risk for obesity and related diseases. Treatments that normalize these alterations may benefit individuals with discrimination-related stress exposure.
Maternal immune activation (MIA) derived from late gestational infection such as seen in chorioamnionitis poses a significantly increased risk for neurodevelopmental deficits in the offspring. Manipulating early microbiota through maternal probiotics supplementation has been shown to be an effective means to improve outcomes, however, the mechanisms remain unclear. In this study we modeled MIA by maternal lipopolysaccharide (LPS) exposure (i.p. injection at E16) and tested the hypothesis that maternal probiotic administration during lactation may rescue the adverse neurodevelopmental outcome of MIA on offspring through the impact on blood-brain barrier (BBB) development and function. T2W, Time of flight, and T1W MRI with contrast were used to evaluate BBB development and permeability at early postnatal age (two weeks of age). Morris water maze test was used to evaluate long term cognitive function at 12 weeks of age. The effects of MIA with or without maternal Limosilactobacillus reuteri (L. reuteri) exposure on gut microbiome and systemic and brain metabolites were investigated using 16S DNA sequencing of fecal samples and metabonomic analysis at both two and 12 weeks of age. We demonstrated that MIA modeled by exposing pregnant dams to LPS induced an underdevelopment of the blood vessels, an increase in permeability and astrogliosis of BBB at pre-wean age. The BBB developmental and functional deficits early in life impaired spatial learning later in life. Maternal L. reuteri supplementation starting at birth rescued the BBB underdevelopment and dysfunction-associated cognitive function. β-diversity was significantly affected by LPS with or without maternal L. reuteri exposure. We further identified two lipid metabolites that can cross the BBB upon LPS insult and fourteen metabolic products of lipid/bile acid metabolism associated with maternal L. reuteri exposure during lactation that can cross the BBB. We conclude that maternal L. reuteri-mediated alterations in β-diversity of the microbial community and metabolic responses in the offspring provide mechanisms and potential targets for promoting BBB integrity and long-term neurodevelopmental outcomes.
Introduction. Several evidence highlights the relevance of microbiota gut-brain axis (MGB) in brain diseases, including Alzheimer's disease (AD). Indeed, AD patients display gut dysbiosis, altered intestinal barrier and enteric neurogenic/inflammatory responses that, besides bowel symptoms, contribute to brain pathology. In this context, the modulation of gut microbiota is emerging as a suitable additional therapeutical option, to target MGB, and to halt or slow down central pathology. This study examined the effects of LACTIPLANTIBACILLUS PLANTARUM (HEAL9), in a spontaneous model of AD.
Methods. Senescence-accelerated mouse prone 8 (SAMP8) mice (4 months old) were employed as a model that develops spontaneously AD and SAMR1 mice as controls. Mice were treated orally with HEAL9 1X109 CFU/mouse/day or placebo for two months (n=6/group) to evaluate the effects of probiotic during the early stages of AD before the full development of brain pathology. Mice underwent Morris water maze test. Then, after assessment of fecal output over one hour, animals were sacrificed, and colonic longitudinal muscle preparations were set up in organ baths and connected to isometric transducers. Neurogenic motor responses were evoked by electrical stimulation (10 Hz) in standard Krebs solution or containing guanethidine (10 μM), L-NAME (100 μM) and NK1, NK2 and NK3 receptor antagonists (10 μM) to record cholinergic contractions. Carbachol (1 μM)-induced myogenic contractions in the presence of tetrodotoxin (1 μM) were also recorded. Plasma and brain and colonic tissues were excised and processed for the evaluation of: 1) β-amyloid (Aβ)1-42 and interleukin-(IL)-1β levels (ELISA); 2) gut barrier alterations (immunofluorescence of claudin-1 tight junction, lipopolysaccharide-binding protein (LBP) levels by ELISA).
Results. SAMP8 mice displayed: 1) cognitive dysfunctions; 2) impaired colonic transit and in vitro contractility, characterized by an altered cholinergic neurotransmission; 3) increased colonic and brain Aβ1-42, IL-1β and plasma LBP levels; 4) altered distribution and decreased expression of colonic claudin-1; 5) altered mucus layer. Intake of HEAL9 counteracted cognitive impairment, colonic motor dysfunctions and decreased brain and colonic Aβ1-42 and IL-1β and plasma LBP levels. HEAL9 also restored colonic claudin-1 expression and distribution.
Conclusions. HEAL9 exerts beneficial effects on AD, by counteracting central and enteric AD-related protein deposition and inflammation and preserving gut barrier integrity. HEAL9 also restored colonic motility through the recovery of cholinergic excitatory neurogenic motility. These results substantiate the concept that the modulation of gut microbiota can represent a suitable additional therapeutical strategy, to target the MGB and to alleviate AD and related intestinal symptoms.
Post-traumatic stress disorder (PTSD) is a mental health disorder triggered by traumatic event/s causing psychiatric and medical morbidities, as well as psychosocial distress. The neurotransmitter serotonin (5-HT) is well-recognized for regulating behavior and emotion. Dysregulation is associated with depression, anxiety, aggression, impulsivity, and suicidal behaviors, all frequently seen in PTSD. 5-HT is synthesized by tryptophan hydroxylase (TPH), acts on 5-HT receptors, and subsequently is deactivated by internalization of 5-HT via the serotonin transporter (SLC6A4, SERT). SSRIs, which target SERT, are commonly used for mood and anxiety disorders, and are the only FDA approved drugs for PTSD. However, the response rate is variable depending upon sex, genetic factors, and environmental factors. 5-HT is abundantly present and synthesized in the gut and alters microbial composition. However, the contribution of intestinal 5-HT and SERT in the progression of PTSD is not understood. Here, we investigated the role of intestinal SERT and its effect on the gut microbiota in the progression of PTSD in a sex-dependent manner. Methods: SERTfl/flxVillin-CreERT2mice (M/F, 8-12 wks) were injected with tamoxifen to induce SERT overexpression in only intestinal epithelial cells (SERT O/EIEC), or corn oil (WT). PTSD mouse model of protracted social isolation (SI) was used as a chronic stressor to elicit aggression in resident-intruder assays. Aggression was measured by the number of attacks, duration of attacks, and onset of attacks. Intestinal mucosa, cecal contents, and brain were collected. Results showed an important role of IEC specific SERT in differentially modulating PTSD-like behavior (aggression) in males and females as evidenced by an increased aggression in isolated SERT O/EIEC males and decreased aggression in SERT O/EIEC single-housed females vs. their respective controls. Reduction in aggression in SERT O/EIEC SI females was concomitant with i) an increase in BDNF and 5a reductase mRNA in amygdala & hippocampus; ii) an increase in ileal MCT10 (SLC16A10, Trp/Phe transporter); iii) increase in Tph-1, a known target of microbiota; iv) an increase in antimicrobial peptides, while isolatedSERT O/EIEC males showed decreases in these pathways. To fully understand the mechanisms underlying these differential responses, we analyzed gut microbiota composition. Pearson correlation analysis in WT and SERT O/EIEC(M/F) showed that gut microbial species from the order-Bacteroidales, Gastranaerophilales, and genus-Anaerotruncus positively correlated with aggression and Desulfovibrio was negatively correlated. Conclusion: These novel data suggest that aggression due to social isolation is modulated by the gut microbiota in a sex-dependent manner via mechanisms involving intestinal serotonergic machinery.
Background:
Intestinal microbial dysbiosis is now recognized as a hallmark of Parkinson’s disease (PD). Our group and others have shown that PD dysbiosis is characterized by increased pro-inflammatory bacteria and reduced abundance of short-chain fatty acid (SCFA)-producing bacteria. SCFAs stimulate enteroendocrine L-cells to secrete glucagon-like peptide-1 (GLP-1), an incretin hormone with neuroprotective properties and protective effects on the intestinal barrier. Here we hypothesize that PD dysbiosis is associated with decreased SCFAs, decreased L-cells, reduced GLP-1 secretion, and intestinal barrier dysfunction, findings that may be reversed by SCFA-promoting prebiotic therapy.

Methods:
We assembled a cohort of 19 PD patients and their spousal controls who provided stool and serum from which we measured SCFA (butyrate, propionate, and acetate) levels by GC-MS. Serum GLP-1 (45 min after consumption of a standard meal), fecal calprotectin, and serum zonulin (marker of intestinal barrier integrity) were measured by ELISA. Outcomes were reassessed after consumption of 10g of prebiotic fiber designed to increase SCFA-producing gut bacteria twice daily for 10 days and analyzed by Wilcoxon-signed rank test for pairwise comparisons. To determine L-cell density from patient-specific crypts, apical-out sigmoid colonoids and ileal enteroids were derived from 14 PD and control subjects, embedded in extracellular protein matrix, and treated with growth factors to expand Lgr5+ stem cells; L-cells were identified immunohistochemically by antibodies to chromogranin and GLP-1.

Results:
Here we demonstrate that compared to healthy control subjects, PD patients contain decreased SCFAs, particularly butyrate, in stool and plasma (p<0.01), corresponding to significantly decreased abundance of intestinal SCFA-producing bacteria such as Bifidobacterium as well as a 2-fold reduction in postprandial GLP-1 secretion (p=0.02) that we previously noted. PD-derived colonic and ileal organoids produce fewer L-cells than healthy organoids (trend). Furthermore, we show significantly increased calprotectin (p=0.044) and decreased intestinal barrier integrity (p<0.001) in PD patients. Our preliminary data show that prebiotic supplementation may restore plasma SCFAs, reduce fecal calprotectin, and improve intestinal barrier integrity.

Conclusions:
Intestinal dysbiosis in PD is associated with decreased 1) abundance of SCFA-producing bacteria, 2) serum and stool SCFAs, 3) GLP-1 secretion, and 4) intestinal barrier integrity, as well as increased fecal calprotectin. Preliminary data suggest these effects can be mitigated by prebiotic supplementation. These findings may hold important implications for impaired neuroprotection (GLP-1) and gut inflammation (barrier integrity and calprotectin) in PD. Future studies will determine the effects of prebiotics on clinical outcomes.
Introduction
Despite achieving endoscopic remission, up to 50% of Inflammatory Bowel Disease (IBD) patients continue to experience chronic abdominal pain, with female patients displaying an increased prevalence. The reason underlying these differences in pain perception is unknown, but the influence of the gut microbiota and sex hormones represent important potential sources for variability in pain sensitivity. Alterations in gut microbiota composition and microbial metabolites (i.e., dysbiosis) are associated with IBD pathogenesis. Previous data from our laboratory demonstrated that microbial-derived short-chain fatty acids (SCFA) were able to sensitize nociceptive neurons in a mouse model of post-inflammatory visceral pain. To date, little is known about sex differences in the gut microbiota or microbial metabolites in chronic visceral pain in IBD.

Aim
Examine the sex-specific gut microbiota differences in post-inflammatory chronic visceral pain in a mouse model of IBD.

Methods
We used the post-inflammatory DSS mouse model of chronic visceral pain. Male and cycling female mice were given 2.5% DSS in drinking water for five days and allowed to recover for 5 weeks. Visceral pain was evaluated using the visceral motor reflex (VMR) to colorectal distension five weeks after DSS treatment; pain testing in females was performed in diestrus. Fecal microbial composition was examined using 16S rRNA gene V4 region amplicon sequencing, and the metabolic profiling was examined using mass spectrometry.

Results
The severity of colitis was significantly lower in female mice than in males [Disease Activity Index at Day 12: 1.41±0.41 females, n=12; 4.41±0.31 males, n=12; p<0.001]. Despite this, post-inflammatory female mice demonstrated increased visceral hypersensitivity compared to post-inflammatory males [VMR at 60mmHg, females 0.10±0.016, n=10; males 0.07± 0.007, n=10; p=0.032] (Figure 1). Post-inflammatory females showed a significant increase (n=11; p<0.001) in alpha diversity. Beta diversity was significantly different in both post-inflammatory males (n=11; p<0.05) and females (n=11; p<0.01) when compared to baseline. An increase in differential abundance, including SCFA-producing Firmicutes like Lachnospiracea and Ruminococaceae, was seen in the post-inflammatory state in both sexes (Figure 2). Fecal acetate (n=5; p<0.0001) and butyrate (n=5; p=0.0123) were increased in post-inflammatory males compared to controls, while SCFA were not significantly different in post-inflammatory females compared to controls.

Conclusion
These data suggest that dysbiosis exists in the post-inflammatory state in both female and male mice, with significant sex differences in microbial metabolites. Identifying sex-specific differences in the gut microbiome in post-inflammatory visceral pain in IBD may allow us to define novel therapeutic approaches for chronic pain in IBD patients.
<b>Figure 1</b><b>. Post-inflammatory female mice exhibit increased visceral pain. </b>Visceral hypersensitivity was measured by evaluating the VMR to CRD.  Data expressed as mean ± SEM, n=10-12 animals/group. Two-way analysis of variance, Tukey post hoc test; p=0.003 at 60mmHg.

Figure 1. Post-inflammatory female mice exhibit increased visceral pain. Visceral hypersensitivity was measured by evaluating the VMR to CRD. Data expressed as mean ± SEM, n=10-12 animals/group. Two-way analysis of variance, Tukey post hoc test; p=0.003 at 60mmHg.

<b>Figure 2. Differential abundance of amplicon sequence variants (ASV) in post-inflammatory male vs post-inflammatory female mice. </b>Log2 fold change of which ASV abundance significantly increased (right) and decreased (left) in males compared to females after 5 weeks of recovery. DESeq2; Wald test.

Figure 2. Differential abundance of amplicon sequence variants (ASV) in post-inflammatory male vs post-inflammatory female mice. Log2 fold change of which ASV abundance significantly increased (right) and decreased (left) in males compared to females after 5 weeks of recovery. DESeq2; Wald test.


09:00am - 10:30am EDT - May 6, 2023 | Room: W190b (McCormick Place)
Jill Tinmouth, Moderator; Peter Liang, Moderator
Society: AGA
Type: Research Forum
Society: AGA


Saturday
Society: AGA

Background: Although colorectal cancer (CRC) screening has been recommended for decades, about one-third of eligible individuals are not up-to-date with screening in the US. The COVID-19 pandemic has worsened this situation. Specific recommendations from health care providers have been found to have a critical role in promoting screening. We aimed to explore the impact of COVID-19 pandemic on CRC screening recommendations and its distinct effects on different populations.
Method: We analyzed the 2019 and 2021 datasets from the National Health Interview Survey (NHIS) in a retrospective cross-sectional study. Using a multistage probability design, the NHIS represents a broad geographical representation of the country. US adults aged 50-75 with no prior CRC and not up-to-date with CRC screening who had available information for CRC screening recommendations were included (N= 4270 [representing 31,665,798] and 3634 [representing 28,496,028] in 2019 and 2021, respectively). The 50-75 age group was considered to have better consistency between 2019 and 2021. A multivariable logistic model was used to identify factors associated with the likelihood of receiving screening recommendations from a provider in the past 12 months. In addition to analysis of the pooled dataset, we conducted separate analyses for 2019 and 2021 to determine if the COVID pandemic disproportionally impacted screening recommendations for specific populations. Weighted frequencies, odds ratio (OR) and confidence interval were estimated.
Results: 1,015 (22.22%) eligible individuals received recommendations for CRC screening in 2019, whereas 660 (17.9%) received them in 2021 (adjusted OR = 0.81, p<.001). Factors associated with less likelihood of receiving a recommendation both in 2019 and 2021 included low income, lack of insurance, racial and ethnic minorities, and no access to a usual care facility. Disparities related to race and insurance coverage became more pronounced in 2021 (Table 1). Also, the higher likelihood of referral in patients with higher education in 2019 was not seen in 2021. Opportunistic referrals were generated from urgent office visits in 2019 vs. emergent hospital visits in 2021.
Conclusion: A lower proportion of eligible individuals received recommendations for CRC screening from a provider during the COVID-19 pandemic in 2021 compared to 2019. While there was a disparity gap in 2019 in individuals with low socio-economic status, ethnic minorities, and those with no access to usual care facility, the gap widened further among ethnic minorities and the uninsured during the COVID-19 pandemic. Targeted efforts are even more needed as a result of the pandemic in order to decrease the disparities gap in CRC screening.

Saturday
Society: AGA

Background: Although colorectal cancer (CRC) screening has been recommended for decades, about one-third of eligible individuals are not up-to-date with screening in the US. The COVID-19 pandemic has worsened this situation. Specific recommendations from health care providers have been found to have a critical role in promoting screening. We aimed to explore the impact of COVID-19 pandemic on CRC screening recommendations and its distinct effects on different populations.
Method: We analyzed the 2019 and 2021 datasets from the National Health Interview Survey (NHIS) in a retrospective cross-sectional study. Using a multistage probability design, the NHIS represents a broad geographical representation of the country. US adults aged 50-75 with no prior CRC and not up-to-date with CRC screening who had available information for CRC screening recommendations were included (N= 4270 [representing 31,665,798] and 3634 [representing 28,496,028] in 2019 and 2021, respectively). The 50-75 age group was considered to have better consistency between 2019 and 2021. A multivariable logistic model was used to identify factors associated with the likelihood of receiving screening recommendations from a provider in the past 12 months. In addition to analysis of the pooled dataset, we conducted separate analyses for 2019 and 2021 to determine if the COVID pandemic disproportionally impacted screening recommendations for specific populations. Weighted frequencies, odds ratio (OR) and confidence interval were estimated.
Results: 1,015 (22.22%) eligible individuals received recommendations for CRC screening in 2019, whereas 660 (17.9%) received them in 2021 (adjusted OR = 0.81, p<.001). Factors associated with less likelihood of receiving a recommendation both in 2019 and 2021 included low income, lack of insurance, racial and ethnic minorities, and no access to a usual care facility. Disparities related to race and insurance coverage became more pronounced in 2021 (Table 1). Also, the higher likelihood of referral in patients with higher education in 2019 was not seen in 2021. Opportunistic referrals were generated from urgent office visits in 2019 vs. emergent hospital visits in 2021.
Conclusion: A lower proportion of eligible individuals received recommendations for CRC screening from a provider during the COVID-19 pandemic in 2021 compared to 2019. While there was a disparity gap in 2019 in individuals with low socio-economic status, ethnic minorities, and those with no access to usual care facility, the gap widened further among ethnic minorities and the uninsured during the COVID-19 pandemic. Targeted efforts are even more needed as a result of the pandemic in order to decrease the disparities gap in CRC screening.
Introduction: Medicaid expansion is a provision in the Affordable Care Act that increases access to health insurance and preventive services for low-income individuals, however not all U.S. states participate. Individuals with Medicaid and in medically underserved areas often receive preventive services at Federally Qualified Health Centers (FQHCs). We aimed to study the impact of Medicaid expansion on colorectal cancer (CRC) screening rates in FQHCs by comparing CRC screening rates and predictors of screening in FQHCs in Medicaid expansion and non-expansion states.

Methods: We used national FQHC quality data from the 2021 Uniform Data System (UDS) to perform a cross-sectional analysis of all U.S FQHCs. We obtained 2021 CRC screening rates for each FQHC and for each state (FQHCs only) for patients age 50-74. (CRC screening data for patients age 45-75 are not available in UDS.) We then used Wilcoxon rank sum and chi-sq tests to compare FQHC patient-mix characteristics based on Medicaid expansion status. Finally, we performed mixed-effects linear regression models to determine FQHC patient-mix characteristics that predict high and low CRC screening participation in FQHCs in Medicaid expansion states and in FQHCs in non-expansion states. Medicaid expansion status was determined from Kaiser Family Foundation data in 11/2022.

Results: Overall, there were 6,940,879 patients eligible for CRC screening in 1,284 U.S. FQHCs in 2021. FQHC patient characteristics differed based on Medicaid expansion status (Table 1). The median CRC screening rate among all FQHCs in 2021 was 40.8%. CRC screening rates were significantly higher in FQHCs in Medicaid expansion states than in non-expansion states (42.1% v. 36.5%, p≤0.0001) (Table 1). In the adjusted model for states without Medicaid expansion, FQHCs in rural settings (urban coef 4.21, 95%CI 0.03, 8.39) or with a high proportion of uninsured patients (coef -10.27, 95%CI -14.00, -6.54) had significantly higher odds of lower CRC screening rates (Table 2). FQHCs located in Medicaid expansion states, however, experienced significantly lower CRC screening rates if they had large proportions of male, Black, Hispanic, low income, unhoused, or uninsured individuals (Table 2).

Discussion: CRC screening rates in U.S. FQHCs are significantly higher in states that implemented Medicaid expansion than in non-expansion states. The impact of being uninsured on participation in CRC screening remains profound in non-expansion states, while race/ethnicity, homelessness, and poverty also predict screening utilization in Medicaid expansion states. Our results suggest that Medicaid expansion states have minimized CRC screening disparities due to uninsured status and that targeted interventions to improve CRC screening participation should differ in FQHCs in Medicaid expansion and non-expansion states.

Saturday
Society: AGA

Background: Although colorectal cancer (CRC) screening has been recommended for decades, about one-third of eligible individuals are not up-to-date with screening in the US. The COVID-19 pandemic has worsened this situation. Specific recommendations from health care providers have been found to have a critical role in promoting screening. We aimed to explore the impact of COVID-19 pandemic on CRC screening recommendations and its distinct effects on different populations.
Method: We analyzed the 2019 and 2021 datasets from the National Health Interview Survey (NHIS) in a retrospective cross-sectional study. Using a multistage probability design, the NHIS represents a broad geographical representation of the country. US adults aged 50-75 with no prior CRC and not up-to-date with CRC screening who had available information for CRC screening recommendations were included (N= 4270 [representing 31,665,798] and 3634 [representing 28,496,028] in 2019 and 2021, respectively). The 50-75 age group was considered to have better consistency between 2019 and 2021. A multivariable logistic model was used to identify factors associated with the likelihood of receiving screening recommendations from a provider in the past 12 months. In addition to analysis of the pooled dataset, we conducted separate analyses for 2019 and 2021 to determine if the COVID pandemic disproportionally impacted screening recommendations for specific populations. Weighted frequencies, odds ratio (OR) and confidence interval were estimated.
Results: 1,015 (22.22%) eligible individuals received recommendations for CRC screening in 2019, whereas 660 (17.9%) received them in 2021 (adjusted OR = 0.81, p<.001). Factors associated with less likelihood of receiving a recommendation both in 2019 and 2021 included low income, lack of insurance, racial and ethnic minorities, and no access to a usual care facility. Disparities related to race and insurance coverage became more pronounced in 2021 (Table 1). Also, the higher likelihood of referral in patients with higher education in 2019 was not seen in 2021. Opportunistic referrals were generated from urgent office visits in 2019 vs. emergent hospital visits in 2021.
Conclusion: A lower proportion of eligible individuals received recommendations for CRC screening from a provider during the COVID-19 pandemic in 2021 compared to 2019. While there was a disparity gap in 2019 in individuals with low socio-economic status, ethnic minorities, and those with no access to usual care facility, the gap widened further among ethnic minorities and the uninsured during the COVID-19 pandemic. Targeted efforts are even more needed as a result of the pandemic in order to decrease the disparities gap in CRC screening.
Introduction: Medicaid expansion is a provision in the Affordable Care Act that increases access to health insurance and preventive services for low-income individuals, however not all U.S. states participate. Individuals with Medicaid and in medically underserved areas often receive preventive services at Federally Qualified Health Centers (FQHCs). We aimed to study the impact of Medicaid expansion on colorectal cancer (CRC) screening rates in FQHCs by comparing CRC screening rates and predictors of screening in FQHCs in Medicaid expansion and non-expansion states.

Methods: We used national FQHC quality data from the 2021 Uniform Data System (UDS) to perform a cross-sectional analysis of all U.S FQHCs. We obtained 2021 CRC screening rates for each FQHC and for each state (FQHCs only) for patients age 50-74. (CRC screening data for patients age 45-75 are not available in UDS.) We then used Wilcoxon rank sum and chi-sq tests to compare FQHC patient-mix characteristics based on Medicaid expansion status. Finally, we performed mixed-effects linear regression models to determine FQHC patient-mix characteristics that predict high and low CRC screening participation in FQHCs in Medicaid expansion states and in FQHCs in non-expansion states. Medicaid expansion status was determined from Kaiser Family Foundation data in 11/2022.

Results: Overall, there were 6,940,879 patients eligible for CRC screening in 1,284 U.S. FQHCs in 2021. FQHC patient characteristics differed based on Medicaid expansion status (Table 1). The median CRC screening rate among all FQHCs in 2021 was 40.8%. CRC screening rates were significantly higher in FQHCs in Medicaid expansion states than in non-expansion states (42.1% v. 36.5%, p≤0.0001) (Table 1). In the adjusted model for states without Medicaid expansion, FQHCs in rural settings (urban coef 4.21, 95%CI 0.03, 8.39) or with a high proportion of uninsured patients (coef -10.27, 95%CI -14.00, -6.54) had significantly higher odds of lower CRC screening rates (Table 2). FQHCs located in Medicaid expansion states, however, experienced significantly lower CRC screening rates if they had large proportions of male, Black, Hispanic, low income, unhoused, or uninsured individuals (Table 2).

Discussion: CRC screening rates in U.S. FQHCs are significantly higher in states that implemented Medicaid expansion than in non-expansion states. The impact of being uninsured on participation in CRC screening remains profound in non-expansion states, while race/ethnicity, homelessness, and poverty also predict screening utilization in Medicaid expansion states. Our results suggest that Medicaid expansion states have minimized CRC screening disparities due to uninsured status and that targeted interventions to improve CRC screening participation should differ in FQHCs in Medicaid expansion and non-expansion states.
Intro: Rates of colorectal cancer screening (CRC) in medically underserved populations (MUPs) are lower compared to the general population, but optimal interventions to improve screening rates in MUPs have not been well-defined. The objectives of this study were to review published interventions aimed at improved CRC screening in MUPs and to identify characteristics associated with successful programs.

Methods: A systematic review of the PubMed, Google, Embase, and Cochrane databases was performed using standard PICO format to construct keyword searches. Studies were included if they described interventions to improve CRC screening in MUPs. Both colonoscopy and stool-based CRC screening methods were included. Studies outside of the United States or that did not include data for baseline, or post-intervention screening rates were excluded. The primary outcome was the success of the intervention, evaluated by calculating the percentage increase (PI) in CRC screening rate ((post-intervention – pre-intervention)/pre-intervention x 100). Interventions that failed to achieve a PI of 125% were not included in the final analysis. Two reviewers assessed each study's eligibility, and a third reviewer served as a tiebreaker. Study quality was evaluated using standard NIH and CASP quality assessment checklist tools. Interventions were grouped by type, and interventions with >2 elements were classified as "multicomponent."

Results: The initial search yielded a total of 572 studies, from which 22 studies including 33 interventions met the criteria for final analysis. Dates ranged from 2003-2018. The mean sample size was 805 ± 1203 (SD) individuals (range: 119-5970). CRC screening method was variable, with 20 interventions to improve rates of stool-based testing and 15 focused on colonoscopy (12 included both). The most common types of interventions included those that were multicomponent (N=19), those that centered around the use of a patient navigator (N=7), and those that primarily used mailings to patients for screening stool-based kits and provider recommendation letters (N=3). The Median PI for the collection of studies was 233% (IQR: 185%, 552%). The most successful interventions were mailer-based kits including a provider letter (median PI 1187%, [IQR:684-1193]), multicomponent interventions (median PI 233% [IQR:187,633]), and interventions using patient navigators (median of 224% [IQR:168,295]).

Conclusion: Randomized studies focused on improving colorectal cancer screening rates in MUPs vary in their definitions of MUP and in intervention type. The most effective published interventions include mailed stool-based kits plus provider letters, those with multiple intervention components, and those built around patient navigation. Clinicians serving MUPs should consider these specific strategies when designing programs to improve CRC screening.

Saturday
Society: AGA

Background: Although colorectal cancer (CRC) screening has been recommended for decades, about one-third of eligible individuals are not up-to-date with screening in the US. The COVID-19 pandemic has worsened this situation. Specific recommendations from health care providers have been found to have a critical role in promoting screening. We aimed to explore the impact of COVID-19 pandemic on CRC screening recommendations and its distinct effects on different populations.
Method: We analyzed the 2019 and 2021 datasets from the National Health Interview Survey (NHIS) in a retrospective cross-sectional study. Using a multistage probability design, the NHIS represents a broad geographical representation of the country. US adults aged 50-75 with no prior CRC and not up-to-date with CRC screening who had available information for CRC screening recommendations were included (N= 4270 [representing 31,665,798] and 3634 [representing 28,496,028] in 2019 and 2021, respectively). The 50-75 age group was considered to have better consistency between 2019 and 2021. A multivariable logistic model was used to identify factors associated with the likelihood of receiving screening recommendations from a provider in the past 12 months. In addition to analysis of the pooled dataset, we conducted separate analyses for 2019 and 2021 to determine if the COVID pandemic disproportionally impacted screening recommendations for specific populations. Weighted frequencies, odds ratio (OR) and confidence interval were estimated.
Results: 1,015 (22.22%) eligible individuals received recommendations for CRC screening in 2019, whereas 660 (17.9%) received them in 2021 (adjusted OR = 0.81, p<.001). Factors associated with less likelihood of receiving a recommendation both in 2019 and 2021 included low income, lack of insurance, racial and ethnic minorities, and no access to a usual care facility. Disparities related to race and insurance coverage became more pronounced in 2021 (Table 1). Also, the higher likelihood of referral in patients with higher education in 2019 was not seen in 2021. Opportunistic referrals were generated from urgent office visits in 2019 vs. emergent hospital visits in 2021.
Conclusion: A lower proportion of eligible individuals received recommendations for CRC screening from a provider during the COVID-19 pandemic in 2021 compared to 2019. While there was a disparity gap in 2019 in individuals with low socio-economic status, ethnic minorities, and those with no access to usual care facility, the gap widened further among ethnic minorities and the uninsured during the COVID-19 pandemic. Targeted efforts are even more needed as a result of the pandemic in order to decrease the disparities gap in CRC screening.
Introduction: Medicaid expansion is a provision in the Affordable Care Act that increases access to health insurance and preventive services for low-income individuals, however not all U.S. states participate. Individuals with Medicaid and in medically underserved areas often receive preventive services at Federally Qualified Health Centers (FQHCs). We aimed to study the impact of Medicaid expansion on colorectal cancer (CRC) screening rates in FQHCs by comparing CRC screening rates and predictors of screening in FQHCs in Medicaid expansion and non-expansion states.

Methods: We used national FQHC quality data from the 2021 Uniform Data System (UDS) to perform a cross-sectional analysis of all U.S FQHCs. We obtained 2021 CRC screening rates for each FQHC and for each state (FQHCs only) for patients age 50-74. (CRC screening data for patients age 45-75 are not available in UDS.) We then used Wilcoxon rank sum and chi-sq tests to compare FQHC patient-mix characteristics based on Medicaid expansion status. Finally, we performed mixed-effects linear regression models to determine FQHC patient-mix characteristics that predict high and low CRC screening participation in FQHCs in Medicaid expansion states and in FQHCs in non-expansion states. Medicaid expansion status was determined from Kaiser Family Foundation data in 11/2022.

Results: Overall, there were 6,940,879 patients eligible for CRC screening in 1,284 U.S. FQHCs in 2021. FQHC patient characteristics differed based on Medicaid expansion status (Table 1). The median CRC screening rate among all FQHCs in 2021 was 40.8%. CRC screening rates were significantly higher in FQHCs in Medicaid expansion states than in non-expansion states (42.1% v. 36.5%, p≤0.0001) (Table 1). In the adjusted model for states without Medicaid expansion, FQHCs in rural settings (urban coef 4.21, 95%CI 0.03, 8.39) or with a high proportion of uninsured patients (coef -10.27, 95%CI -14.00, -6.54) had significantly higher odds of lower CRC screening rates (Table 2). FQHCs located in Medicaid expansion states, however, experienced significantly lower CRC screening rates if they had large proportions of male, Black, Hispanic, low income, unhoused, or uninsured individuals (Table 2).

Discussion: CRC screening rates in U.S. FQHCs are significantly higher in states that implemented Medicaid expansion than in non-expansion states. The impact of being uninsured on participation in CRC screening remains profound in non-expansion states, while race/ethnicity, homelessness, and poverty also predict screening utilization in Medicaid expansion states. Our results suggest that Medicaid expansion states have minimized CRC screening disparities due to uninsured status and that targeted interventions to improve CRC screening participation should differ in FQHCs in Medicaid expansion and non-expansion states.
Intro: Rates of colorectal cancer screening (CRC) in medically underserved populations (MUPs) are lower compared to the general population, but optimal interventions to improve screening rates in MUPs have not been well-defined. The objectives of this study were to review published interventions aimed at improved CRC screening in MUPs and to identify characteristics associated with successful programs.

Methods: A systematic review of the PubMed, Google, Embase, and Cochrane databases was performed using standard PICO format to construct keyword searches. Studies were included if they described interventions to improve CRC screening in MUPs. Both colonoscopy and stool-based CRC screening methods were included. Studies outside of the United States or that did not include data for baseline, or post-intervention screening rates were excluded. The primary outcome was the success of the intervention, evaluated by calculating the percentage increase (PI) in CRC screening rate ((post-intervention – pre-intervention)/pre-intervention x 100). Interventions that failed to achieve a PI of 125% were not included in the final analysis. Two reviewers assessed each study's eligibility, and a third reviewer served as a tiebreaker. Study quality was evaluated using standard NIH and CASP quality assessment checklist tools. Interventions were grouped by type, and interventions with >2 elements were classified as "multicomponent."

Results: The initial search yielded a total of 572 studies, from which 22 studies including 33 interventions met the criteria for final analysis. Dates ranged from 2003-2018. The mean sample size was 805 ± 1203 (SD) individuals (range: 119-5970). CRC screening method was variable, with 20 interventions to improve rates of stool-based testing and 15 focused on colonoscopy (12 included both). The most common types of interventions included those that were multicomponent (N=19), those that centered around the use of a patient navigator (N=7), and those that primarily used mailings to patients for screening stool-based kits and provider recommendation letters (N=3). The Median PI for the collection of studies was 233% (IQR: 185%, 552%). The most successful interventions were mailer-based kits including a provider letter (median PI 1187%, [IQR:684-1193]), multicomponent interventions (median PI 233% [IQR:187,633]), and interventions using patient navigators (median of 224% [IQR:168,295]).

Conclusion: Randomized studies focused on improving colorectal cancer screening rates in MUPs vary in their definitions of MUP and in intervention type. The most effective published interventions include mailed stool-based kits plus provider letters, those with multiple intervention components, and those built around patient navigation. Clinicians serving MUPs should consider these specific strategies when designing programs to improve CRC screening.
Background: <20% of individuals suspicious for Lynch syndrome and other inherited cancer syndromes undergo genetic testing in the US. Undiagnosed patients will not benefit from enhanced cancer screening and prophylactic interventions. It is imperative we find mechanisms to dramatically improve the identification of candidates for LS genetic testing.
Method: We created a patient registry by converting National Comprehensive Cancer Network (NCCN)/American College of Medical Genetics based genetic testing criteria for all cancer syndromes into distinct rule-based conditional logic statements in the HER. The registry leverages structured data from the EHR including personal and familial history. Here we report patients identified because they met NCCN genetic testing criteria for Lynch syndrome. Patient evaluation status, as well as data on demographic, socio-economic, and clinical factors were collected. Next, logistic regression modeling was exploited to identify independent determinants of likelihood for evaluation. Association of determinants with evaluation status was adjusted for personal and family history of cancer in the model.

Results: Among 4,090 individuals meeting testing criteria for Lynch syndrome, only 1,118 (27.33%) had been evaluated. The mean age of the patients included was 49.88±15.45 and 3,173 (77.6%) were female (Table 1). Hispanic and non-Hispanic African Americans (OR=0.55 and OR=0.56, both P<.001 compared to non-Hispanic White) and individuals with Medicaid or Medicare insurance (OR=0.55, P<.001 and OR=0.56, P<.001 compared to commercial insurance) had been less likely evaluated (Table 2). In contrast, female patients (Odds ratio (OR) = 1.25, P=.01 vs males), and those with higher number of office visits in the prior three years (OR = 2.07, P<.001 in those with >38 visits) had more likely been evaluated.

Conclusion: The novel EHR-based algorithm identified many individuals that by current standard of care criteria should undergo genetic testing to rule out Lynch syndrome, yet they had not been identified by providers. Among those, less than a third had undergone testing, with the lowest numbers among the underserved and publicly insured populations. In spite that eligible Medicaid patients have genetic testing covered in Connecticut, these patients were still less likely to receive genetic testing to rule out Lynch syndrome than other patients cared for by the same health system. The use of tools as the one we developed can have an important impact in the identification of LS patients and can decisively contribute to decrease disparities.

Saturday
Society: AGA

Background: Although colorectal cancer (CRC) screening has been recommended for decades, about one-third of eligible individuals are not up-to-date with screening in the US. The COVID-19 pandemic has worsened this situation. Specific recommendations from health care providers have been found to have a critical role in promoting screening. We aimed to explore the impact of COVID-19 pandemic on CRC screening recommendations and its distinct effects on different populations.
Method: We analyzed the 2019 and 2021 datasets from the National Health Interview Survey (NHIS) in a retrospective cross-sectional study. Using a multistage probability design, the NHIS represents a broad geographical representation of the country. US adults aged 50-75 with no prior CRC and not up-to-date with CRC screening who had available information for CRC screening recommendations were included (N= 4270 [representing 31,665,798] and 3634 [representing 28,496,028] in 2019 and 2021, respectively). The 50-75 age group was considered to have better consistency between 2019 and 2021. A multivariable logistic model was used to identify factors associated with the likelihood of receiving screening recommendations from a provider in the past 12 months. In addition to analysis of the pooled dataset, we conducted separate analyses for 2019 and 2021 to determine if the COVID pandemic disproportionally impacted screening recommendations for specific populations. Weighted frequencies, odds ratio (OR) and confidence interval were estimated.
Results: 1,015 (22.22%) eligible individuals received recommendations for CRC screening in 2019, whereas 660 (17.9%) received them in 2021 (adjusted OR = 0.81, p<.001). Factors associated with less likelihood of receiving a recommendation both in 2019 and 2021 included low income, lack of insurance, racial and ethnic minorities, and no access to a usual care facility. Disparities related to race and insurance coverage became more pronounced in 2021 (Table 1). Also, the higher likelihood of referral in patients with higher education in 2019 was not seen in 2021. Opportunistic referrals were generated from urgent office visits in 2019 vs. emergent hospital visits in 2021.
Conclusion: A lower proportion of eligible individuals received recommendations for CRC screening from a provider during the COVID-19 pandemic in 2021 compared to 2019. While there was a disparity gap in 2019 in individuals with low socio-economic status, ethnic minorities, and those with no access to usual care facility, the gap widened further among ethnic minorities and the uninsured during the COVID-19 pandemic. Targeted efforts are even more needed as a result of the pandemic in order to decrease the disparities gap in CRC screening.
Introduction: Medicaid expansion is a provision in the Affordable Care Act that increases access to health insurance and preventive services for low-income individuals, however not all U.S. states participate. Individuals with Medicaid and in medically underserved areas often receive preventive services at Federally Qualified Health Centers (FQHCs). We aimed to study the impact of Medicaid expansion on colorectal cancer (CRC) screening rates in FQHCs by comparing CRC screening rates and predictors of screening in FQHCs in Medicaid expansion and non-expansion states.

Methods: We used national FQHC quality data from the 2021 Uniform Data System (UDS) to perform a cross-sectional analysis of all U.S FQHCs. We obtained 2021 CRC screening rates for each FQHC and for each state (FQHCs only) for patients age 50-74. (CRC screening data for patients age 45-75 are not available in UDS.) We then used Wilcoxon rank sum and chi-sq tests to compare FQHC patient-mix characteristics based on Medicaid expansion status. Finally, we performed mixed-effects linear regression models to determine FQHC patient-mix characteristics that predict high and low CRC screening participation in FQHCs in Medicaid expansion states and in FQHCs in non-expansion states. Medicaid expansion status was determined from Kaiser Family Foundation data in 11/2022.

Results: Overall, there were 6,940,879 patients eligible for CRC screening in 1,284 U.S. FQHCs in 2021. FQHC patient characteristics differed based on Medicaid expansion status (Table 1). The median CRC screening rate among all FQHCs in 2021 was 40.8%. CRC screening rates were significantly higher in FQHCs in Medicaid expansion states than in non-expansion states (42.1% v. 36.5%, p≤0.0001) (Table 1). In the adjusted model for states without Medicaid expansion, FQHCs in rural settings (urban coef 4.21, 95%CI 0.03, 8.39) or with a high proportion of uninsured patients (coef -10.27, 95%CI -14.00, -6.54) had significantly higher odds of lower CRC screening rates (Table 2). FQHCs located in Medicaid expansion states, however, experienced significantly lower CRC screening rates if they had large proportions of male, Black, Hispanic, low income, unhoused, or uninsured individuals (Table 2).

Discussion: CRC screening rates in U.S. FQHCs are significantly higher in states that implemented Medicaid expansion than in non-expansion states. The impact of being uninsured on participation in CRC screening remains profound in non-expansion states, while race/ethnicity, homelessness, and poverty also predict screening utilization in Medicaid expansion states. Our results suggest that Medicaid expansion states have minimized CRC screening disparities due to uninsured status and that targeted interventions to improve CRC screening participation should differ in FQHCs in Medicaid expansion and non-expansion states.
Intro: Rates of colorectal cancer screening (CRC) in medically underserved populations (MUPs) are lower compared to the general population, but optimal interventions to improve screening rates in MUPs have not been well-defined. The objectives of this study were to review published interventions aimed at improved CRC screening in MUPs and to identify characteristics associated with successful programs.

Methods: A systematic review of the PubMed, Google, Embase, and Cochrane databases was performed using standard PICO format to construct keyword searches. Studies were included if they described interventions to improve CRC screening in MUPs. Both colonoscopy and stool-based CRC screening methods were included. Studies outside of the United States or that did not include data for baseline, or post-intervention screening rates were excluded. The primary outcome was the success of the intervention, evaluated by calculating the percentage increase (PI) in CRC screening rate ((post-intervention – pre-intervention)/pre-intervention x 100). Interventions that failed to achieve a PI of 125% were not included in the final analysis. Two reviewers assessed each study's eligibility, and a third reviewer served as a tiebreaker. Study quality was evaluated using standard NIH and CASP quality assessment checklist tools. Interventions were grouped by type, and interventions with >2 elements were classified as "multicomponent."

Results: The initial search yielded a total of 572 studies, from which 22 studies including 33 interventions met the criteria for final analysis. Dates ranged from 2003-2018. The mean sample size was 805 ± 1203 (SD) individuals (range: 119-5970). CRC screening method was variable, with 20 interventions to improve rates of stool-based testing and 15 focused on colonoscopy (12 included both). The most common types of interventions included those that were multicomponent (N=19), those that centered around the use of a patient navigator (N=7), and those that primarily used mailings to patients for screening stool-based kits and provider recommendation letters (N=3). The Median PI for the collection of studies was 233% (IQR: 185%, 552%). The most successful interventions were mailer-based kits including a provider letter (median PI 1187%, [IQR:684-1193]), multicomponent interventions (median PI 233% [IQR:187,633]), and interventions using patient navigators (median of 224% [IQR:168,295]).

Conclusion: Randomized studies focused on improving colorectal cancer screening rates in MUPs vary in their definitions of MUP and in intervention type. The most effective published interventions include mailed stool-based kits plus provider letters, those with multiple intervention components, and those built around patient navigation. Clinicians serving MUPs should consider these specific strategies when designing programs to improve CRC screening.
Background: <20% of individuals suspicious for Lynch syndrome and other inherited cancer syndromes undergo genetic testing in the US. Undiagnosed patients will not benefit from enhanced cancer screening and prophylactic interventions. It is imperative we find mechanisms to dramatically improve the identification of candidates for LS genetic testing.
Method: We created a patient registry by converting National Comprehensive Cancer Network (NCCN)/American College of Medical Genetics based genetic testing criteria for all cancer syndromes into distinct rule-based conditional logic statements in the HER. The registry leverages structured data from the EHR including personal and familial history. Here we report patients identified because they met NCCN genetic testing criteria for Lynch syndrome. Patient evaluation status, as well as data on demographic, socio-economic, and clinical factors were collected. Next, logistic regression modeling was exploited to identify independent determinants of likelihood for evaluation. Association of determinants with evaluation status was adjusted for personal and family history of cancer in the model.

Results: Among 4,090 individuals meeting testing criteria for Lynch syndrome, only 1,118 (27.33%) had been evaluated. The mean age of the patients included was 49.88±15.45 and 3,173 (77.6%) were female (Table 1). Hispanic and non-Hispanic African Americans (OR=0.55 and OR=0.56, both P<.001 compared to non-Hispanic White) and individuals with Medicaid or Medicare insurance (OR=0.55, P<.001 and OR=0.56, P<.001 compared to commercial insurance) had been less likely evaluated (Table 2). In contrast, female patients (Odds ratio (OR) = 1.25, P=.01 vs males), and those with higher number of office visits in the prior three years (OR = 2.07, P<.001 in those with >38 visits) had more likely been evaluated.

Conclusion: The novel EHR-based algorithm identified many individuals that by current standard of care criteria should undergo genetic testing to rule out Lynch syndrome, yet they had not been identified by providers. Among those, less than a third had undergone testing, with the lowest numbers among the underserved and publicly insured populations. In spite that eligible Medicaid patients have genetic testing covered in Connecticut, these patients were still less likely to receive genetic testing to rule out Lynch syndrome than other patients cared for by the same health system. The use of tools as the one we developed can have an important impact in the identification of LS patients and can decisively contribute to decrease disparities.
Introduction: Federally Qualified Health Centers (FQHCs) offer preventive health services, including colorectal cancer (CRC) screening, for low-income and under-insured individuals in the United States (U.S.). CRC screening rates in FQHCs increased from 2014 to 2019 but declined in 2020, coinciding with the beginning of the COVID-19 pandemic. We assessed changes in CRC screening rates and clinic-level factors associated with changes in screening rates from 2020 to 2021 in U.S. FQHCs.

Methods: We performed a series of cross-sectional analyses using data from the Uniform Data System (2014-2021). We abstracted annual CRC screening rates at FQHCs for patients ages 50-74 and determined screening rate trends over time nationally, in California, and in Los Angeles County. We then calculated the change in the CRC screening rate from 2020 to 2021 for each FQHC. Lastly, we used multivariate mixed effects linear regression models to determine characteristics associated with the change in CRC screening rate nationally, in California, and in Los Angeles County, controlling for FQHC characteristics, 2020 screening rates, and number of screening-eligible patients in 2021.

Results: Across all FQHCs (n=1,284), 6,940,879 patients were eligible for CRC screening in 2021. Median FQHC national screening rates steadily increased from 30.0% in 2014 to 42.9% in 2019, declined to 38.8% in 2020, and then increased to 40.8% in 2021. Screening rates in California (median 36.8%; n=166) and Los Angeles (median 37.3%; n=58) fell below the national FQHC screening rate for the first time in 2020. The median FQHC screening rate in California increased slightly to 39.0% in 2021 yet remained below the national FQHC median rate (Figure). In the national mixed effects linear regression model, FQHCs that served a majority of Black patients saw a significant screening rate decline (Coefficient -1.34; 95%CI -2.66, -0.01). This association was more pronounced in the California model, where FQHCs serving majority Black patients had a 9.73-point decline in CRC screening rate (95%CI -18.04, -1.44). Conversely, in California FQHCs serving majority non-Hispanic Asian/Pacific Islander, American Indian, or other race/ethnicity patients, screening rates increased in 2021 (Coefficient 5.59; 95%CI 0.20, 10.98) (Table). Significant clinic-level associations in the national and California models were not statistically significant in the Los Angeles County model.

Discussion: CRC screening rates rebounded in U.S. FQHCs in 2021 but did not return to pre-pandemic levels. In addition, recovery did not occur in majority-Black FQHCs where screening rates, on average, continued to decline. Future studies must further characterize disparities in screening rate recovery after the COVID-19 pandemic, as targeted interventions may be essential towards addressing worsening disparities in CRC screening participation.
<b>Figure.</b> Annual median colorectal cancer screening rates in Federally Qualified Health Centers in the United States (blue), in California State (orange), and in Los Angeles County (gray) from 2014 to 2021.

Figure. Annual median colorectal cancer screening rates in Federally Qualified Health Centers in the United States (blue), in California State (orange), and in Los Angeles County (gray) from 2014 to 2021.

<b>Table</b>. Clinic-level factors associated with colorectal cancer (CRC) screening rate change from 2020 to 2021 at Federally Qualified Health Centers (FQHCs) in the United States and California, based on mixed effects linear regression.

Table. Clinic-level factors associated with colorectal cancer (CRC) screening rate change from 2020 to 2021 at Federally Qualified Health Centers (FQHCs) in the United States and California, based on mixed effects linear regression.


Saturday
10:15am - 10:30am EDT - May 6, 2023 | Room: W190b (McCormick Place)
Society: AGA
Type: Research Forum
Society: AGA

Background: Although colorectal cancer (CRC) screening has been recommended for decades, about one-third of eligible individuals are not up-to-date with screening in the US. The COVID-19 pandemic has worsened this situation. Specific recommendations from health care providers have been found to have a critical role in promoting screening. We aimed to explore the impact of COVID-19 pandemic on CRC screening recommendations and its distinct effects on different populations.
Method: We analyzed the 2019 and 2021 datasets from the National Health Interview Survey (NHIS) in a retrospective cross-sectional study. Using a multistage probability design, the NHIS represents a broad geographical representation of the country. US adults aged 50-75 with no prior CRC and not up-to-date with CRC screening who had available information for CRC screening recommendations were included (N= 4270 [representing 31,665,798] and 3634 [representing 28,496,028] in 2019 and 2021, respectively). The 50-75 age group was considered to have better consistency between 2019 and 2021. A multivariable logistic model was used to identify factors associated with the likelihood of receiving screening recommendations from a provider in the past 12 months. In addition to analysis of the pooled dataset, we conducted separate analyses for 2019 and 2021 to determine if the COVID pandemic disproportionally impacted screening recommendations for specific populations. Weighted frequencies, odds ratio (OR) and confidence interval were estimated.
Results: 1,015 (22.22%) eligible individuals received recommendations for CRC screening in 2019, whereas 660 (17.9%) received them in 2021 (adjusted OR = 0.81, p<.001). Factors associated with less likelihood of receiving a recommendation both in 2019 and 2021 included low income, lack of insurance, racial and ethnic minorities, and no access to a usual care facility. Disparities related to race and insurance coverage became more pronounced in 2021 (Table 1). Also, the higher likelihood of referral in patients with higher education in 2019 was not seen in 2021. Opportunistic referrals were generated from urgent office visits in 2019 vs. emergent hospital visits in 2021.
Conclusion: A lower proportion of eligible individuals received recommendations for CRC screening from a provider during the COVID-19 pandemic in 2021 compared to 2019. While there was a disparity gap in 2019 in individuals with low socio-economic status, ethnic minorities, and those with no access to usual care facility, the gap widened further among ethnic minorities and the uninsured during the COVID-19 pandemic. Targeted efforts are even more needed as a result of the pandemic in order to decrease the disparities gap in CRC screening.
Introduction: Medicaid expansion is a provision in the Affordable Care Act that increases access to health insurance and preventive services for low-income individuals, however not all U.S. states participate. Individuals with Medicaid and in medically underserved areas often receive preventive services at Federally Qualified Health Centers (FQHCs). We aimed to study the impact of Medicaid expansion on colorectal cancer (CRC) screening rates in FQHCs by comparing CRC screening rates and predictors of screening in FQHCs in Medicaid expansion and non-expansion states.

Methods: We used national FQHC quality data from the 2021 Uniform Data System (UDS) to perform a cross-sectional analysis of all U.S FQHCs. We obtained 2021 CRC screening rates for each FQHC and for each state (FQHCs only) for patients age 50-74. (CRC screening data for patients age 45-75 are not available in UDS.) We then used Wilcoxon rank sum and chi-sq tests to compare FQHC patient-mix characteristics based on Medicaid expansion status. Finally, we performed mixed-effects linear regression models to determine FQHC patient-mix characteristics that predict high and low CRC screening participation in FQHCs in Medicaid expansion states and in FQHCs in non-expansion states. Medicaid expansion status was determined from Kaiser Family Foundation data in 11/2022.

Results: Overall, there were 6,940,879 patients eligible for CRC screening in 1,284 U.S. FQHCs in 2021. FQHC patient characteristics differed based on Medicaid expansion status (Table 1). The median CRC screening rate among all FQHCs in 2021 was 40.8%. CRC screening rates were significantly higher in FQHCs in Medicaid expansion states than in non-expansion states (42.1% v. 36.5%, p≤0.0001) (Table 1). In the adjusted model for states without Medicaid expansion, FQHCs in rural settings (urban coef 4.21, 95%CI 0.03, 8.39) or with a high proportion of uninsured patients (coef -10.27, 95%CI -14.00, -6.54) had significantly higher odds of lower CRC screening rates (Table 2). FQHCs located in Medicaid expansion states, however, experienced significantly lower CRC screening rates if they had large proportions of male, Black, Hispanic, low income, unhoused, or uninsured individuals (Table 2).

Discussion: CRC screening rates in U.S. FQHCs are significantly higher in states that implemented Medicaid expansion than in non-expansion states. The impact of being uninsured on participation in CRC screening remains profound in non-expansion states, while race/ethnicity, homelessness, and poverty also predict screening utilization in Medicaid expansion states. Our results suggest that Medicaid expansion states have minimized CRC screening disparities due to uninsured status and that targeted interventions to improve CRC screening participation should differ in FQHCs in Medicaid expansion and non-expansion states.
Intro: Rates of colorectal cancer screening (CRC) in medically underserved populations (MUPs) are lower compared to the general population, but optimal interventions to improve screening rates in MUPs have not been well-defined. The objectives of this study were to review published interventions aimed at improved CRC screening in MUPs and to identify characteristics associated with successful programs.

Methods: A systematic review of the PubMed, Google, Embase, and Cochrane databases was performed using standard PICO format to construct keyword searches. Studies were included if they described interventions to improve CRC screening in MUPs. Both colonoscopy and stool-based CRC screening methods were included. Studies outside of the United States or that did not include data for baseline, or post-intervention screening rates were excluded. The primary outcome was the success of the intervention, evaluated by calculating the percentage increase (PI) in CRC screening rate ((post-intervention – pre-intervention)/pre-intervention x 100). Interventions that failed to achieve a PI of 125% were not included in the final analysis. Two reviewers assessed each study's eligibility, and a third reviewer served as a tiebreaker. Study quality was evaluated using standard NIH and CASP quality assessment checklist tools. Interventions were grouped by type, and interventions with >2 elements were classified as "multicomponent."

Results: The initial search yielded a total of 572 studies, from which 22 studies including 33 interventions met the criteria for final analysis. Dates ranged from 2003-2018. The mean sample size was 805 ± 1203 (SD) individuals (range: 119-5970). CRC screening method was variable, with 20 interventions to improve rates of stool-based testing and 15 focused on colonoscopy (12 included both). The most common types of interventions included those that were multicomponent (N=19), those that centered around the use of a patient navigator (N=7), and those that primarily used mailings to patients for screening stool-based kits and provider recommendation letters (N=3). The Median PI for the collection of studies was 233% (IQR: 185%, 552%). The most successful interventions were mailer-based kits including a provider letter (median PI 1187%, [IQR:684-1193]), multicomponent interventions (median PI 233% [IQR:187,633]), and interventions using patient navigators (median of 224% [IQR:168,295]).

Conclusion: Randomized studies focused on improving colorectal cancer screening rates in MUPs vary in their definitions of MUP and in intervention type. The most effective published interventions include mailed stool-based kits plus provider letters, those with multiple intervention components, and those built around patient navigation. Clinicians serving MUPs should consider these specific strategies when designing programs to improve CRC screening.
Background: <20% of individuals suspicious for Lynch syndrome and other inherited cancer syndromes undergo genetic testing in the US. Undiagnosed patients will not benefit from enhanced cancer screening and prophylactic interventions. It is imperative we find mechanisms to dramatically improve the identification of candidates for LS genetic testing.
Method: We created a patient registry by converting National Comprehensive Cancer Network (NCCN)/American College of Medical Genetics based genetic testing criteria for all cancer syndromes into distinct rule-based conditional logic statements in the HER. The registry leverages structured data from the EHR including personal and familial history. Here we report patients identified because they met NCCN genetic testing criteria for Lynch syndrome. Patient evaluation status, as well as data on demographic, socio-economic, and clinical factors were collected. Next, logistic regression modeling was exploited to identify independent determinants of likelihood for evaluation. Association of determinants with evaluation status was adjusted for personal and family history of cancer in the model.

Results: Among 4,090 individuals meeting testing criteria for Lynch syndrome, only 1,118 (27.33%) had been evaluated. The mean age of the patients included was 49.88±15.45 and 3,173 (77.6%) were female (Table 1). Hispanic and non-Hispanic African Americans (OR=0.55 and OR=0.56, both P<.001 compared to non-Hispanic White) and individuals with Medicaid or Medicare insurance (OR=0.55, P<.001 and OR=0.56, P<.001 compared to commercial insurance) had been less likely evaluated (Table 2). In contrast, female patients (Odds ratio (OR) = 1.25, P=.01 vs males), and those with higher number of office visits in the prior three years (OR = 2.07, P<.001 in those with >38 visits) had more likely been evaluated.

Conclusion: The novel EHR-based algorithm identified many individuals that by current standard of care criteria should undergo genetic testing to rule out Lynch syndrome, yet they had not been identified by providers. Among those, less than a third had undergone testing, with the lowest numbers among the underserved and publicly insured populations. In spite that eligible Medicaid patients have genetic testing covered in Connecticut, these patients were still less likely to receive genetic testing to rule out Lynch syndrome than other patients cared for by the same health system. The use of tools as the one we developed can have an important impact in the identification of LS patients and can decisively contribute to decrease disparities.
Introduction: Federally Qualified Health Centers (FQHCs) offer preventive health services, including colorectal cancer (CRC) screening, for low-income and under-insured individuals in the United States (U.S.). CRC screening rates in FQHCs increased from 2014 to 2019 but declined in 2020, coinciding with the beginning of the COVID-19 pandemic. We assessed changes in CRC screening rates and clinic-level factors associated with changes in screening rates from 2020 to 2021 in U.S. FQHCs.

Methods: We performed a series of cross-sectional analyses using data from the Uniform Data System (2014-2021). We abstracted annual CRC screening rates at FQHCs for patients ages 50-74 and determined screening rate trends over time nationally, in California, and in Los Angeles County. We then calculated the change in the CRC screening rate from 2020 to 2021 for each FQHC. Lastly, we used multivariate mixed effects linear regression models to determine characteristics associated with the change in CRC screening rate nationally, in California, and in Los Angeles County, controlling for FQHC characteristics, 2020 screening rates, and number of screening-eligible patients in 2021.

Results: Across all FQHCs (n=1,284), 6,940,879 patients were eligible for CRC screening in 2021. Median FQHC national screening rates steadily increased from 30.0% in 2014 to 42.9% in 2019, declined to 38.8% in 2020, and then increased to 40.8% in 2021. Screening rates in California (median 36.8%; n=166) and Los Angeles (median 37.3%; n=58) fell below the national FQHC screening rate for the first time in 2020. The median FQHC screening rate in California increased slightly to 39.0% in 2021 yet remained below the national FQHC median rate (Figure). In the national mixed effects linear regression model, FQHCs that served a majority of Black patients saw a significant screening rate decline (Coefficient -1.34; 95%CI -2.66, -0.01). This association was more pronounced in the California model, where FQHCs serving majority Black patients had a 9.73-point decline in CRC screening rate (95%CI -18.04, -1.44). Conversely, in California FQHCs serving majority non-Hispanic Asian/Pacific Islander, American Indian, or other race/ethnicity patients, screening rates increased in 2021 (Coefficient 5.59; 95%CI 0.20, 10.98) (Table). Significant clinic-level associations in the national and California models were not statistically significant in the Los Angeles County model.

Discussion: CRC screening rates rebounded in U.S. FQHCs in 2021 but did not return to pre-pandemic levels. In addition, recovery did not occur in majority-Black FQHCs where screening rates, on average, continued to decline. Future studies must further characterize disparities in screening rate recovery after the COVID-19 pandemic, as targeted interventions may be essential towards addressing worsening disparities in CRC screening participation.
<b>Figure.</b> Annual median colorectal cancer screening rates in Federally Qualified Health Centers in the United States (blue), in California State (orange), and in Los Angeles County (gray) from 2014 to 2021.

Figure. Annual median colorectal cancer screening rates in Federally Qualified Health Centers in the United States (blue), in California State (orange), and in Los Angeles County (gray) from 2014 to 2021.

<b>Table</b>. Clinic-level factors associated with colorectal cancer (CRC) screening rate change from 2020 to 2021 at Federally Qualified Health Centers (FQHCs) in the United States and California, based on mixed effects linear regression.

Table. Clinic-level factors associated with colorectal cancer (CRC) screening rate change from 2020 to 2021 at Federally Qualified Health Centers (FQHCs) in the United States and California, based on mixed effects linear regression.


09:00am - 10:30am EDT - May 6, 2023 | Room: W193 (McCormick Place)
Robert Shulman, Moderator; Mirna Chehade, Moderator
Society: AGA
Type: Research Forum
Tags: Pediatric GI
Society: AGA


Saturday
09:00am - 09:23am EDT - May 6, 2023 | Room: W193 (McCormick Place)
Salvatore Oliva, Presenter
Society: AGA
Type: Research Forum
Society: AGA


Saturday
09:23am - 09:34am EDT - May 6, 2023 | Room: W193 (McCormick Place)
Society: AGA
Type: Research Forum
Society: AGA

Background: While it is widely recognized that symptoms of eosinophilic esophagitis (EoE) differ in children versus adults, only a single case series has investigated symptoms of EoE in infants and toddlers, and few young children are included in studies of therapeutic response. Thus, the aims of the current study were 1) to characterize presentations of EoE in children < 2 years, and 2) to evaluate histologic and clinical response to treatment in this youngest pediatric age group.

Methods: This was a retrospective longitudinal study of children < 2 years diagnosed with EoE at a single tertiary center between 2016 and 2018. EoE was defined histologically by presence of > 15 eosinophils per high power field (eos/hpf) on at least one esophageal biopsy and a history suggestive of the diagnosis. Demographic characteristics, presenting symptoms, and EoE treatments were collected via chart review. Follow-up data were collected from all endoscopies after diagnosis, and histologic remission was defined as < 15 eos/hpf. Paired t-tests or Fisher exact tests for parametric data or Wilcoxin sign-rank test for non-parametric data were used to evaluate changes from baseline to follow-up in histology and clinical symptoms.

Results: Forty-two children ages 1.3 ± 0.4 years were followed for a mean of 3.6 ± 1.7 years and underwent 3.8 ± 2.3 (range 1 to 10) endoscopies under general anesthesia. Common presenting symptoms were feeding difficulties in 67% of patients (including gagging/coughing with feeding in 60% and difficulty with progression to pureed or solid foods in 43%), vomiting (57%), and coughing/wheezing (52%). Thirty-six children (86%) were male, and comorbidities included atopy (86%), reflux (74%), and a history of cow’s milk protein allergy (40%). Thirty-seven patients underwent repeat endoscopy after diagnosis, and 25/37 (68%) achieved histologic remission during the follow-up period. In addition to histologic improvement, there were significant reductions in all symptoms at follow-up compared to baseline (Figure 1). Treatment regimens were variable, and there was a significant effect of therapy type on histologic response (P = 0.004) with the best responses on combinations of diet/steroids or diet/proton pump inhibitor (PPI) and the worst response on PPIs alone (Figure 2). Of the 20 patients who underwent additional endoscopies after histologic remission, 13/20 (65%) had relapsed EoE on at least one follow-up endoscopy.

Discussion: The diagnosis of EoE should be considered in infants and toddlers presenting with feeding difficulties, vomiting, and cough or wheeze. EoE in this age group may mimic other common GI diagnoses, such as reflux or milk protein intolerance. Most patients show histologic and clinical improvements with standard therapies, but the endoscopic burden is significant and histologic response may not be maintained over time.
Percent of patients with symptoms pre- and post-treatment for eosinophilic esophagitis with corresponding P-values. Circles indicate the median peak eosinophil count at baseline and triangles indicate the median peak eosinophil count at follow-up among patients presenting with that symptom.

Percent of patients with symptoms pre- and post-treatment for eosinophilic esophagitis with corresponding P-values. Circles indicate the median peak eosinophil count at baseline and triangles indicate the median peak eosinophil count at follow-up among patients presenting with that symptom.

Proportion of patients achieving histologic remission (defined by peak eosinophil count < 15 per high power field) by EoE treatment.

Proportion of patients achieving histologic remission (defined by peak eosinophil count < 15 per high power field) by EoE treatment.


Saturday
Society: AGA

Background: While it is widely recognized that symptoms of eosinophilic esophagitis (EoE) differ in children versus adults, only a single case series has investigated symptoms of EoE in infants and toddlers, and few young children are included in studies of therapeutic response. Thus, the aims of the current study were 1) to characterize presentations of EoE in children < 2 years, and 2) to evaluate histologic and clinical response to treatment in this youngest pediatric age group.

Methods: This was a retrospective longitudinal study of children < 2 years diagnosed with EoE at a single tertiary center between 2016 and 2018. EoE was defined histologically by presence of > 15 eosinophils per high power field (eos/hpf) on at least one esophageal biopsy and a history suggestive of the diagnosis. Demographic characteristics, presenting symptoms, and EoE treatments were collected via chart review. Follow-up data were collected from all endoscopies after diagnosis, and histologic remission was defined as < 15 eos/hpf. Paired t-tests or Fisher exact tests for parametric data or Wilcoxin sign-rank test for non-parametric data were used to evaluate changes from baseline to follow-up in histology and clinical symptoms.

Results: Forty-two children ages 1.3 ± 0.4 years were followed for a mean of 3.6 ± 1.7 years and underwent 3.8 ± 2.3 (range 1 to 10) endoscopies under general anesthesia. Common presenting symptoms were feeding difficulties in 67% of patients (including gagging/coughing with feeding in 60% and difficulty with progression to pureed or solid foods in 43%), vomiting (57%), and coughing/wheezing (52%). Thirty-six children (86%) were male, and comorbidities included atopy (86%), reflux (74%), and a history of cow’s milk protein allergy (40%). Thirty-seven patients underwent repeat endoscopy after diagnosis, and 25/37 (68%) achieved histologic remission during the follow-up period. In addition to histologic improvement, there were significant reductions in all symptoms at follow-up compared to baseline (Figure 1). Treatment regimens were variable, and there was a significant effect of therapy type on histologic response (P = 0.004) with the best responses on combinations of diet/steroids or diet/proton pump inhibitor (PPI) and the worst response on PPIs alone (Figure 2). Of the 20 patients who underwent additional endoscopies after histologic remission, 13/20 (65%) had relapsed EoE on at least one follow-up endoscopy.

Discussion: The diagnosis of EoE should be considered in infants and toddlers presenting with feeding difficulties, vomiting, and cough or wheeze. EoE in this age group may mimic other common GI diagnoses, such as reflux or milk protein intolerance. Most patients show histologic and clinical improvements with standard therapies, but the endoscopic burden is significant and histologic response may not be maintained over time.
Percent of patients with symptoms pre- and post-treatment for eosinophilic esophagitis with corresponding P-values. Circles indicate the median peak eosinophil count at baseline and triangles indicate the median peak eosinophil count at follow-up among patients presenting with that symptom.

Percent of patients with symptoms pre- and post-treatment for eosinophilic esophagitis with corresponding P-values. Circles indicate the median peak eosinophil count at baseline and triangles indicate the median peak eosinophil count at follow-up among patients presenting with that symptom.

Proportion of patients achieving histologic remission (defined by peak eosinophil count < 15 per high power field) by EoE treatment.

Proportion of patients achieving histologic remission (defined by peak eosinophil count < 15 per high power field) by EoE treatment.

Background: Helicobacter pylori (H. pylori) eradication rates have declined globally making susceptibility testing increasingly important. Despite improvement in test availability of gastric biopsy-culture with susceptibility testing (gold standard) in the United States (US), culture requires an invasive procedure to obtain gastric biopsies, esophagogastroduodenoscopy (EGD), which is not devoid of potential endoscopic and anesthesia-related risks. Stool-based susceptibility testing offers a useful non-invasive option suitable for pediatric population in whom invasive diagnostic testing for the sole purpose of detecting H pylori infection is not recommended.
Methods: A total of 19 patients that underwent diagnostic endoscopic evaluation with positive resultant positive histology for H. pylori from a large pediatric tertiary care center in Boston, MA were included in the study. At our institution, we have standardized the process of gastric biopsy culture in patients with endoscopic findings of H. pylori. An antral and corpus biopsy are taken at the time of endoscopy for gastric biopsy-culture with susceptibility testing via agar dilution. Patients provided a stool sample within 2 weeks of the endoscopy, prior to the start of treatment. We evaluated agreement between the stool next generation sequencing (NGS)-based molecular testing and gastric biopsy-culture with susceptibility testing.
Results: From the 19 recruited patients, 6 (31.6%) did not have sufficient bacterial colony growth in gastric culture to run susceptibility testing. Sufficient H. pylori DNA for NGS analysis was detected in 18 (95%) patients. Thirteen patients (68.4%) had both stool NGS-based molecular test, and gastric biopsy-culture antimicrobial resistance data to compare (mean age 11.9 years [range 3-20], 6 (46%) Male, 6 (46%) Black, 4 (31%) Hispanic. Overall stool NGS-based molecular test was highly concordant with gastric biopsy-culture results for clarithromycin resistance (2 patients), and no resistance identified (11 patients). In addition, stool NGS-based molecular test was highly sensitive, providing antimicrobial resistance data in patients with poor bacterial growth in culture (5/6, 83%). All of the 5 patients were resistant to at least one antimicrobial.
Conclusion: Stool NGS-based molecular test is highly concordant with gastric biopsy-culture results, providing accurate H. pylori antimicrobial resistance data for clarithromycin non-invasively in pediatric patients.

Saturday
Society: AGA

Background: While it is widely recognized that symptoms of eosinophilic esophagitis (EoE) differ in children versus adults, only a single case series has investigated symptoms of EoE in infants and toddlers, and few young children are included in studies of therapeutic response. Thus, the aims of the current study were 1) to characterize presentations of EoE in children < 2 years, and 2) to evaluate histologic and clinical response to treatment in this youngest pediatric age group.

Methods: This was a retrospective longitudinal study of children < 2 years diagnosed with EoE at a single tertiary center between 2016 and 2018. EoE was defined histologically by presence of > 15 eosinophils per high power field (eos/hpf) on at least one esophageal biopsy and a history suggestive of the diagnosis. Demographic characteristics, presenting symptoms, and EoE treatments were collected via chart review. Follow-up data were collected from all endoscopies after diagnosis, and histologic remission was defined as < 15 eos/hpf. Paired t-tests or Fisher exact tests for parametric data or Wilcoxin sign-rank test for non-parametric data were used to evaluate changes from baseline to follow-up in histology and clinical symptoms.

Results: Forty-two children ages 1.3 ± 0.4 years were followed for a mean of 3.6 ± 1.7 years and underwent 3.8 ± 2.3 (range 1 to 10) endoscopies under general anesthesia. Common presenting symptoms were feeding difficulties in 67% of patients (including gagging/coughing with feeding in 60% and difficulty with progression to pureed or solid foods in 43%), vomiting (57%), and coughing/wheezing (52%). Thirty-six children (86%) were male, and comorbidities included atopy (86%), reflux (74%), and a history of cow’s milk protein allergy (40%). Thirty-seven patients underwent repeat endoscopy after diagnosis, and 25/37 (68%) achieved histologic remission during the follow-up period. In addition to histologic improvement, there were significant reductions in all symptoms at follow-up compared to baseline (Figure 1). Treatment regimens were variable, and there was a significant effect of therapy type on histologic response (P = 0.004) with the best responses on combinations of diet/steroids or diet/proton pump inhibitor (PPI) and the worst response on PPIs alone (Figure 2). Of the 20 patients who underwent additional endoscopies after histologic remission, 13/20 (65%) had relapsed EoE on at least one follow-up endoscopy.

Discussion: The diagnosis of EoE should be considered in infants and toddlers presenting with feeding difficulties, vomiting, and cough or wheeze. EoE in this age group may mimic other common GI diagnoses, such as reflux or milk protein intolerance. Most patients show histologic and clinical improvements with standard therapies, but the endoscopic burden is significant and histologic response may not be maintained over time.
Percent of patients with symptoms pre- and post-treatment for eosinophilic esophagitis with corresponding P-values. Circles indicate the median peak eosinophil count at baseline and triangles indicate the median peak eosinophil count at follow-up among patients presenting with that symptom.

Percent of patients with symptoms pre- and post-treatment for eosinophilic esophagitis with corresponding P-values. Circles indicate the median peak eosinophil count at baseline and triangles indicate the median peak eosinophil count at follow-up among patients presenting with that symptom.

Proportion of patients achieving histologic remission (defined by peak eosinophil count < 15 per high power field) by EoE treatment.

Proportion of patients achieving histologic remission (defined by peak eosinophil count < 15 per high power field) by EoE treatment.

Background: Helicobacter pylori (H. pylori) eradication rates have declined globally making susceptibility testing increasingly important. Despite improvement in test availability of gastric biopsy-culture with susceptibility testing (gold standard) in the United States (US), culture requires an invasive procedure to obtain gastric biopsies, esophagogastroduodenoscopy (EGD), which is not devoid of potential endoscopic and anesthesia-related risks. Stool-based susceptibility testing offers a useful non-invasive option suitable for pediatric population in whom invasive diagnostic testing for the sole purpose of detecting H pylori infection is not recommended.
Methods: A total of 19 patients that underwent diagnostic endoscopic evaluation with positive resultant positive histology for H. pylori from a large pediatric tertiary care center in Boston, MA were included in the study. At our institution, we have standardized the process of gastric biopsy culture in patients with endoscopic findings of H. pylori. An antral and corpus biopsy are taken at the time of endoscopy for gastric biopsy-culture with susceptibility testing via agar dilution. Patients provided a stool sample within 2 weeks of the endoscopy, prior to the start of treatment. We evaluated agreement between the stool next generation sequencing (NGS)-based molecular testing and gastric biopsy-culture with susceptibility testing.
Results: From the 19 recruited patients, 6 (31.6%) did not have sufficient bacterial colony growth in gastric culture to run susceptibility testing. Sufficient H. pylori DNA for NGS analysis was detected in 18 (95%) patients. Thirteen patients (68.4%) had both stool NGS-based molecular test, and gastric biopsy-culture antimicrobial resistance data to compare (mean age 11.9 years [range 3-20], 6 (46%) Male, 6 (46%) Black, 4 (31%) Hispanic. Overall stool NGS-based molecular test was highly concordant with gastric biopsy-culture results for clarithromycin resistance (2 patients), and no resistance identified (11 patients). In addition, stool NGS-based molecular test was highly sensitive, providing antimicrobial resistance data in patients with poor bacterial growth in culture (5/6, 83%). All of the 5 patients were resistant to at least one antimicrobial.
Conclusion: Stool NGS-based molecular test is highly concordant with gastric biopsy-culture results, providing accurate H. pylori antimicrobial resistance data for clarithromycin non-invasively in pediatric patients.
Introduction:
Celiac disease is a gluten-mediated autoimmune enteropathy with an estimated prevalence of 2-3% of the population. Recent reports suggest that SARS-CoV-2 infections may increase the risk of celiac disease by increasing intestinal inflammatory responses that may alter intestinal permeability with potential post-inflammatory and autoimmune sequelae. ACE2 receptors, which have been associated with COVID-19, are widely expressed in enterocytes. SARS-CoV-2 infection has also been associated with the presence of tissue transglutaminase autoantibodies (TGA). The aim of this study was to evaluate the potential association of COVID-19 infection and celiac disease autoimmunity.

Methods:
Cross-sectional screening for SARS-CoV-2 antibodies and TGA IgA for celiac disease was offered to children in Colorado through the Autoimmunity Screening for Kids (ASK) study. From July 2020 through December 2021, 4717 Colorado children participated in antibody screening. Children were screened at Children’s Hospital Colorado, Denver Health community clinics, private pediatric practices, and other community sites. Previous SARS-CoV-2 infection was defined by presence of antibodies to the receptor-binding domain of the spike protein in unvaccinated subjects and presence of nucleocapsid antibodies in vaccinated subjects. Multivariable logistic regression was used to assess independent association between previous SARS-CoV-2 infection and celiac autoimmunity.

Results:
There were 109 participants who screened positive for celiac disease (2.3%) and 219 reported a first-degree relative with celiac disease (4.6%). Analysis showed previous SARS-CoV-2 infection in 1524 of 4717 children (32.3%) between July 2020 and December 2021 (median age 8.6 years; 50.3% female). Twenty-seven children of 1524 with prior COVID-19 infection were TGA positive. COVID-19 infection was more frequent in older children (p=<0.001 for age as a continuous variable), those without family history of celiac disease (p<0.0001), Hispanics (p<0.0001), and unvaccinated (p=0.0001).

In multivariable logistic regression, previous SARS-CoV-2 infection was not associated with presence of TGA in Colorado children (OR=1.02, 95% CI 0.63-1.59; p=0.95), adjusting for sex, age, race/ethnicity, and family history of celiac disease in first-degree relatives. (Table 1)

Conclusions:
Previous SARS-CoV-2 infection was not associated with celiac disease autoimmunity in Colorado children. To our knowledge, this is the first large-scale analysis of celiac disease autoimmunity during the COVID-19 pandemic. Longer prospective analysis will help assess whether there is a true association between SARS-CoV-2 infection and prevalence of autoimmunity in children.
Table 1. Results of Multivariable Logistic Regression for an Association Between Autoantibodies and SARS-CoV-2 Antibody Status (n=4717)

Table 1. Results of Multivariable Logistic Regression for an Association Between Autoantibodies and SARS-CoV-2 Antibody Status (n=4717)


Saturday
Society: AGA

Background: While it is widely recognized that symptoms of eosinophilic esophagitis (EoE) differ in children versus adults, only a single case series has investigated symptoms of EoE in infants and toddlers, and few young children are included in studies of therapeutic response. Thus, the aims of the current study were 1) to characterize presentations of EoE in children < 2 years, and 2) to evaluate histologic and clinical response to treatment in this youngest pediatric age group.

Methods: This was a retrospective longitudinal study of children < 2 years diagnosed with EoE at a single tertiary center between 2016 and 2018. EoE was defined histologically by presence of > 15 eosinophils per high power field (eos/hpf) on at least one esophageal biopsy and a history suggestive of the diagnosis. Demographic characteristics, presenting symptoms, and EoE treatments were collected via chart review. Follow-up data were collected from all endoscopies after diagnosis, and histologic remission was defined as < 15 eos/hpf. Paired t-tests or Fisher exact tests for parametric data or Wilcoxin sign-rank test for non-parametric data were used to evaluate changes from baseline to follow-up in histology and clinical symptoms.

Results: Forty-two children ages 1.3 ± 0.4 years were followed for a mean of 3.6 ± 1.7 years and underwent 3.8 ± 2.3 (range 1 to 10) endoscopies under general anesthesia. Common presenting symptoms were feeding difficulties in 67% of patients (including gagging/coughing with feeding in 60% and difficulty with progression to pureed or solid foods in 43%), vomiting (57%), and coughing/wheezing (52%). Thirty-six children (86%) were male, and comorbidities included atopy (86%), reflux (74%), and a history of cow’s milk protein allergy (40%). Thirty-seven patients underwent repeat endoscopy after diagnosis, and 25/37 (68%) achieved histologic remission during the follow-up period. In addition to histologic improvement, there were significant reductions in all symptoms at follow-up compared to baseline (Figure 1). Treatment regimens were variable, and there was a significant effect of therapy type on histologic response (P = 0.004) with the best responses on combinations of diet/steroids or diet/proton pump inhibitor (PPI) and the worst response on PPIs alone (Figure 2). Of the 20 patients who underwent additional endoscopies after histologic remission, 13/20 (65%) had relapsed EoE on at least one follow-up endoscopy.

Discussion: The diagnosis of EoE should be considered in infants and toddlers presenting with feeding difficulties, vomiting, and cough or wheeze. EoE in this age group may mimic other common GI diagnoses, such as reflux or milk protein intolerance. Most patients show histologic and clinical improvements with standard therapies, but the endoscopic burden is significant and histologic response may not be maintained over time.
Percent of patients with symptoms pre- and post-treatment for eosinophilic esophagitis with corresponding P-values. Circles indicate the median peak eosinophil count at baseline and triangles indicate the median peak eosinophil count at follow-up among patients presenting with that symptom.

Percent of patients with symptoms pre- and post-treatment for eosinophilic esophagitis with corresponding P-values. Circles indicate the median peak eosinophil count at baseline and triangles indicate the median peak eosinophil count at follow-up among patients presenting with that symptom.

Proportion of patients achieving histologic remission (defined by peak eosinophil count < 15 per high power field) by EoE treatment.

Proportion of patients achieving histologic remission (defined by peak eosinophil count < 15 per high power field) by EoE treatment.

Background: Helicobacter pylori (H. pylori) eradication rates have declined globally making susceptibility testing increasingly important. Despite improvement in test availability of gastric biopsy-culture with susceptibility testing (gold standard) in the United States (US), culture requires an invasive procedure to obtain gastric biopsies, esophagogastroduodenoscopy (EGD), which is not devoid of potential endoscopic and anesthesia-related risks. Stool-based susceptibility testing offers a useful non-invasive option suitable for pediatric population in whom invasive diagnostic testing for the sole purpose of detecting H pylori infection is not recommended.
Methods: A total of 19 patients that underwent diagnostic endoscopic evaluation with positive resultant positive histology for H. pylori from a large pediatric tertiary care center in Boston, MA were included in the study. At our institution, we have standardized the process of gastric biopsy culture in patients with endoscopic findings of H. pylori. An antral and corpus biopsy are taken at the time of endoscopy for gastric biopsy-culture with susceptibility testing via agar dilution. Patients provided a stool sample within 2 weeks of the endoscopy, prior to the start of treatment. We evaluated agreement between the stool next generation sequencing (NGS)-based molecular testing and gastric biopsy-culture with susceptibility testing.
Results: From the 19 recruited patients, 6 (31.6%) did not have sufficient bacterial colony growth in gastric culture to run susceptibility testing. Sufficient H. pylori DNA for NGS analysis was detected in 18 (95%) patients. Thirteen patients (68.4%) had both stool NGS-based molecular test, and gastric biopsy-culture antimicrobial resistance data to compare (mean age 11.9 years [range 3-20], 6 (46%) Male, 6 (46%) Black, 4 (31%) Hispanic. Overall stool NGS-based molecular test was highly concordant with gastric biopsy-culture results for clarithromycin resistance (2 patients), and no resistance identified (11 patients). In addition, stool NGS-based molecular test was highly sensitive, providing antimicrobial resistance data in patients with poor bacterial growth in culture (5/6, 83%). All of the 5 patients were resistant to at least one antimicrobial.
Conclusion: Stool NGS-based molecular test is highly concordant with gastric biopsy-culture results, providing accurate H. pylori antimicrobial resistance data for clarithromycin non-invasively in pediatric patients.
Introduction:
Celiac disease is a gluten-mediated autoimmune enteropathy with an estimated prevalence of 2-3% of the population. Recent reports suggest that SARS-CoV-2 infections may increase the risk of celiac disease by increasing intestinal inflammatory responses that may alter intestinal permeability with potential post-inflammatory and autoimmune sequelae. ACE2 receptors, which have been associated with COVID-19, are widely expressed in enterocytes. SARS-CoV-2 infection has also been associated with the presence of tissue transglutaminase autoantibodies (TGA). The aim of this study was to evaluate the potential association of COVID-19 infection and celiac disease autoimmunity.

Methods:
Cross-sectional screening for SARS-CoV-2 antibodies and TGA IgA for celiac disease was offered to children in Colorado through the Autoimmunity Screening for Kids (ASK) study. From July 2020 through December 2021, 4717 Colorado children participated in antibody screening. Children were screened at Children’s Hospital Colorado, Denver Health community clinics, private pediatric practices, and other community sites. Previous SARS-CoV-2 infection was defined by presence of antibodies to the receptor-binding domain of the spike protein in unvaccinated subjects and presence of nucleocapsid antibodies in vaccinated subjects. Multivariable logistic regression was used to assess independent association between previous SARS-CoV-2 infection and celiac autoimmunity.

Results:
There were 109 participants who screened positive for celiac disease (2.3%) and 219 reported a first-degree relative with celiac disease (4.6%). Analysis showed previous SARS-CoV-2 infection in 1524 of 4717 children (32.3%) between July 2020 and December 2021 (median age 8.6 years; 50.3% female). Twenty-seven children of 1524 with prior COVID-19 infection were TGA positive. COVID-19 infection was more frequent in older children (p=<0.001 for age as a continuous variable), those without family history of celiac disease (p<0.0001), Hispanics (p<0.0001), and unvaccinated (p=0.0001).

In multivariable logistic regression, previous SARS-CoV-2 infection was not associated with presence of TGA in Colorado children (OR=1.02, 95% CI 0.63-1.59; p=0.95), adjusting for sex, age, race/ethnicity, and family history of celiac disease in first-degree relatives. (Table 1)

Conclusions:
Previous SARS-CoV-2 infection was not associated with celiac disease autoimmunity in Colorado children. To our knowledge, this is the first large-scale analysis of celiac disease autoimmunity during the COVID-19 pandemic. Longer prospective analysis will help assess whether there is a true association between SARS-CoV-2 infection and prevalence of autoimmunity in children.
Table 1. Results of Multivariable Logistic Regression for an Association Between Autoantibodies and SARS-CoV-2 Antibody Status (n=4717)

Table 1. Results of Multivariable Logistic Regression for an Association Between Autoantibodies and SARS-CoV-2 Antibody Status (n=4717)

Background Severe Acute Malnutrition (SAM) in African children carries high mortality when complicated by infection or metabolic derangements. As malnutrition enteropathy (diarrhoea, microbial translocation, malabsorption) is a prominent feature of complicated SAM we evaluated four novel interventions in children with complicated SAM.
Methods This was a multi-arm, phase II, non-blinded randomised controlled trial in two hospitals in Lusaka, Zambia, and Harare, Zimbabwe. Children were randomised to 14 days of i) bovine colostrum, ii) N-acetyl glucosamine, iii) budesonide, iv) subcutaneous teduglutide, or v) standard care alone. The primary endpoint was a composite of faecal biomarkers (myeloperoxidase, neopterin and α1-antitrypsin). Secondary endpoints were biomarkers of mucosal damage, inflammation, microbial translocation, clinical recovery, anthropometry, adverse events and mortality. A subgroup additionally underwent endoscopy for small intestinal biopsy. Per-protocol analysis used ANCOVA, adjusted for baseline biomarker value, sex, oedema, HIV status, diarrhoea, weight-for-length Z-score, and study site, with pre-specified significance of P<0.10.
Results Between May 2020 and April 2021, 125 children were randomised and 122 (98%) contributed endpoint data. The faecal biomarker score (median at baseline 1.87) was reduced by teduglutide by 0.89 (95%CI -0.06, 1.85) compared with standard care (P=0.07 by ANCOVA). Teduglutide and colostrum increased crypt depth in mucosal biopsies compared to standard care (median 197mm (IQR 149,221) versus 151mm (IQR 136,162); P=0.02). Budesonide reduced plasma C-reactive protein and CD163, while colostrum and N-acetyl glucosamine reduced CRP only. N-acetyl glucosamine reduced diarrhoea by 89% (rate ratio 0.11; 90%CI 0.04, 0.33). Adverse Events were not different between treatment arms.
Conclusions All interventions were safe. Teduglutide reduced markers of malnutrition enteropathy, and budesonide reduced systemic inflammation. Further trials are warranted to establish clinical efficacy, optimal timing and duration of interventions for SAM.

Saturday
10:07am - 10:30am EDT - May 6, 2023 | Room: W193 (McCormick Place)
Maria Mearin, Presenter
Society: AGA
Type: Research Forum
Society: AGA

Background: While it is widely recognized that symptoms of eosinophilic esophagitis (EoE) differ in children versus adults, only a single case series has investigated symptoms of EoE in infants and toddlers, and few young children are included in studies of therapeutic response. Thus, the aims of the current study were 1) to characterize presentations of EoE in children < 2 years, and 2) to evaluate histologic and clinical response to treatment in this youngest pediatric age group.

Methods: This was a retrospective longitudinal study of children < 2 years diagnosed with EoE at a single tertiary center between 2016 and 2018. EoE was defined histologically by presence of > 15 eosinophils per high power field (eos/hpf) on at least one esophageal biopsy and a history suggestive of the diagnosis. Demographic characteristics, presenting symptoms, and EoE treatments were collected via chart review. Follow-up data were collected from all endoscopies after diagnosis, and histologic remission was defined as < 15 eos/hpf. Paired t-tests or Fisher exact tests for parametric data or Wilcoxin sign-rank test for non-parametric data were used to evaluate changes from baseline to follow-up in histology and clinical symptoms.

Results: Forty-two children ages 1.3 ± 0.4 years were followed for a mean of 3.6 ± 1.7 years and underwent 3.8 ± 2.3 (range 1 to 10) endoscopies under general anesthesia. Common presenting symptoms were feeding difficulties in 67% of patients (including gagging/coughing with feeding in 60% and difficulty with progression to pureed or solid foods in 43%), vomiting (57%), and coughing/wheezing (52%). Thirty-six children (86%) were male, and comorbidities included atopy (86%), reflux (74%), and a history of cow’s milk protein allergy (40%). Thirty-seven patients underwent repeat endoscopy after diagnosis, and 25/37 (68%) achieved histologic remission during the follow-up period. In addition to histologic improvement, there were significant reductions in all symptoms at follow-up compared to baseline (Figure 1). Treatment regimens were variable, and there was a significant effect of therapy type on histologic response (P = 0.004) with the best responses on combinations of diet/steroids or diet/proton pump inhibitor (PPI) and the worst response on PPIs alone (Figure 2). Of the 20 patients who underwent additional endoscopies after histologic remission, 13/20 (65%) had relapsed EoE on at least one follow-up endoscopy.

Discussion: The diagnosis of EoE should be considered in infants and toddlers presenting with feeding difficulties, vomiting, and cough or wheeze. EoE in this age group may mimic other common GI diagnoses, such as reflux or milk protein intolerance. Most patients show histologic and clinical improvements with standard therapies, but the endoscopic burden is significant and histologic response may not be maintained over time.
Percent of patients with symptoms pre- and post-treatment for eosinophilic esophagitis with corresponding P-values. Circles indicate the median peak eosinophil count at baseline and triangles indicate the median peak eosinophil count at follow-up among patients presenting with that symptom.

Percent of patients with symptoms pre- and post-treatment for eosinophilic esophagitis with corresponding P-values. Circles indicate the median peak eosinophil count at baseline and triangles indicate the median peak eosinophil count at follow-up among patients presenting with that symptom.

Proportion of patients achieving histologic remission (defined by peak eosinophil count < 15 per high power field) by EoE treatment.

Proportion of patients achieving histologic remission (defined by peak eosinophil count < 15 per high power field) by EoE treatment.

Background: Helicobacter pylori (H. pylori) eradication rates have declined globally making susceptibility testing increasingly important. Despite improvement in test availability of gastric biopsy-culture with susceptibility testing (gold standard) in the United States (US), culture requires an invasive procedure to obtain gastric biopsies, esophagogastroduodenoscopy (EGD), which is not devoid of potential endoscopic and anesthesia-related risks. Stool-based susceptibility testing offers a useful non-invasive option suitable for pediatric population in whom invasive diagnostic testing for the sole purpose of detecting H pylori infection is not recommended.
Methods: A total of 19 patients that underwent diagnostic endoscopic evaluation with positive resultant positive histology for H. pylori from a large pediatric tertiary care center in Boston, MA were included in the study. At our institution, we have standardized the process of gastric biopsy culture in patients with endoscopic findings of H. pylori. An antral and corpus biopsy are taken at the time of endoscopy for gastric biopsy-culture with susceptibility testing via agar dilution. Patients provided a stool sample within 2 weeks of the endoscopy, prior to the start of treatment. We evaluated agreement between the stool next generation sequencing (NGS)-based molecular testing and gastric biopsy-culture with susceptibility testing.
Results: From the 19 recruited patients, 6 (31.6%) did not have sufficient bacterial colony growth in gastric culture to run susceptibility testing. Sufficient H. pylori DNA for NGS analysis was detected in 18 (95%) patients. Thirteen patients (68.4%) had both stool NGS-based molecular test, and gastric biopsy-culture antimicrobial resistance data to compare (mean age 11.9 years [range 3-20], 6 (46%) Male, 6 (46%) Black, 4 (31%) Hispanic. Overall stool NGS-based molecular test was highly concordant with gastric biopsy-culture results for clarithromycin resistance (2 patients), and no resistance identified (11 patients). In addition, stool NGS-based molecular test was highly sensitive, providing antimicrobial resistance data in patients with poor bacterial growth in culture (5/6, 83%). All of the 5 patients were resistant to at least one antimicrobial.
Conclusion: Stool NGS-based molecular test is highly concordant with gastric biopsy-culture results, providing accurate H. pylori antimicrobial resistance data for clarithromycin non-invasively in pediatric patients.
Introduction:
Celiac disease is a gluten-mediated autoimmune enteropathy with an estimated prevalence of 2-3% of the population. Recent reports suggest that SARS-CoV-2 infections may increase the risk of celiac disease by increasing intestinal inflammatory responses that may alter intestinal permeability with potential post-inflammatory and autoimmune sequelae. ACE2 receptors, which have been associated with COVID-19, are widely expressed in enterocytes. SARS-CoV-2 infection has also been associated with the presence of tissue transglutaminase autoantibodies (TGA). The aim of this study was to evaluate the potential association of COVID-19 infection and celiac disease autoimmunity.

Methods:
Cross-sectional screening for SARS-CoV-2 antibodies and TGA IgA for celiac disease was offered to children in Colorado through the Autoimmunity Screening for Kids (ASK) study. From July 2020 through December 2021, 4717 Colorado children participated in antibody screening. Children were screened at Children’s Hospital Colorado, Denver Health community clinics, private pediatric practices, and other community sites. Previous SARS-CoV-2 infection was defined by presence of antibodies to the receptor-binding domain of the spike protein in unvaccinated subjects and presence of nucleocapsid antibodies in vaccinated subjects. Multivariable logistic regression was used to assess independent association between previous SARS-CoV-2 infection and celiac autoimmunity.

Results:
There were 109 participants who screened positive for celiac disease (2.3%) and 219 reported a first-degree relative with celiac disease (4.6%). Analysis showed previous SARS-CoV-2 infection in 1524 of 4717 children (32.3%) between July 2020 and December 2021 (median age 8.6 years; 50.3% female). Twenty-seven children of 1524 with prior COVID-19 infection were TGA positive. COVID-19 infection was more frequent in older children (p=<0.001 for age as a continuous variable), those without family history of celiac disease (p<0.0001), Hispanics (p<0.0001), and unvaccinated (p=0.0001).

In multivariable logistic regression, previous SARS-CoV-2 infection was not associated with presence of TGA in Colorado children (OR=1.02, 95% CI 0.63-1.59; p=0.95), adjusting for sex, age, race/ethnicity, and family history of celiac disease in first-degree relatives. (Table 1)

Conclusions:
Previous SARS-CoV-2 infection was not associated with celiac disease autoimmunity in Colorado children. To our knowledge, this is the first large-scale analysis of celiac disease autoimmunity during the COVID-19 pandemic. Longer prospective analysis will help assess whether there is a true association between SARS-CoV-2 infection and prevalence of autoimmunity in children.
Table 1. Results of Multivariable Logistic Regression for an Association Between Autoantibodies and SARS-CoV-2 Antibody Status (n=4717)

Table 1. Results of Multivariable Logistic Regression for an Association Between Autoantibodies and SARS-CoV-2 Antibody Status (n=4717)

Background Severe Acute Malnutrition (SAM) in African children carries high mortality when complicated by infection or metabolic derangements. As malnutrition enteropathy (diarrhoea, microbial translocation, malabsorption) is a prominent feature of complicated SAM we evaluated four novel interventions in children with complicated SAM.
Methods This was a multi-arm, phase II, non-blinded randomised controlled trial in two hospitals in Lusaka, Zambia, and Harare, Zimbabwe. Children were randomised to 14 days of i) bovine colostrum, ii) N-acetyl glucosamine, iii) budesonide, iv) subcutaneous teduglutide, or v) standard care alone. The primary endpoint was a composite of faecal biomarkers (myeloperoxidase, neopterin and α1-antitrypsin). Secondary endpoints were biomarkers of mucosal damage, inflammation, microbial translocation, clinical recovery, anthropometry, adverse events and mortality. A subgroup additionally underwent endoscopy for small intestinal biopsy. Per-protocol analysis used ANCOVA, adjusted for baseline biomarker value, sex, oedema, HIV status, diarrhoea, weight-for-length Z-score, and study site, with pre-specified significance of P<0.10.
Results Between May 2020 and April 2021, 125 children were randomised and 122 (98%) contributed endpoint data. The faecal biomarker score (median at baseline 1.87) was reduced by teduglutide by 0.89 (95%CI -0.06, 1.85) compared with standard care (P=0.07 by ANCOVA). Teduglutide and colostrum increased crypt depth in mucosal biopsies compared to standard care (median 197mm (IQR 149,221) versus 151mm (IQR 136,162); P=0.02). Budesonide reduced plasma C-reactive protein and CD163, while colostrum and N-acetyl glucosamine reduced CRP only. N-acetyl glucosamine reduced diarrhoea by 89% (rate ratio 0.11; 90%CI 0.04, 0.33). Adverse Events were not different between treatment arms.
Conclusions All interventions were safe. Teduglutide reduced markers of malnutrition enteropathy, and budesonide reduced systemic inflammation. Further trials are warranted to establish clinical efficacy, optimal timing and duration of interventions for SAM.

09:00am - 10:30am EDT - May 6, 2023 | Room: S105bc (McCormick Place)
Society: AGA
Type: Research Forum
Society: AGA


Saturday
Society: AGA

Background: Postoperative ileus (POI) is a common consequence of abdominal surgery and a neuroinflammation-based disorder of the gastrointestinal tract, which results in motility disturbances compromising patients' recovery. The underlying neuroinflammation involves the activation of resident macrophages and monocyte-derived macrophages (MDM) infiltration into the intestine's muscularis externa (ME). Immune checkpoint proteins, including PD-1 and its ligands PD-L1 and PD-L2, play a prominent role in cancer immunology, but their role in non-oncological inflammation-driven diseases is still elusive. Herein, we studied the role of PD-1/PD-L1/PD-L2 signaling in POI.
Materials and methods: POI was induced by a surgical intestinal manipulation in wildtype, PD-1-/-, PD-L1-/- and PD-L2-/- mice. We performed flow cytometry to identify the cellular sources of PD-1 and PD-L1 and used a blood cell transfer model to determine the role of a leukocyte-restricted PD-1 deficiency. qPCR and SMART-Seq2 analyses were used to analyze transcriptomes of sorted CX3CR1GFP MDM from wildtype and PD-1-/- macrophage populations. Immunofluorescence microscopy visualized neuronal cell loss, PD-1 and PD-L2 expression and in vivo macrophage phagocytosis assay and GI transit measurements were used as functional readouts of PD-1 deficiency.
Results: PD-1, PD-L1 and PD-L2 mRNA levels were induced in the postoperative ME upon intestinal manipulation. PD-1-/- and PD-L1-/- but not PD-L2-/- mice were protected from POI- PD-1-/- mice showed a 50% reduction of MDM infiltration and reduced inflammation-mediated neuronal loss. Ly6C-Cx3CR1+ resident macrophages and Ly6C+Cx3CR1+ MDM were identified as the primary cellular source of PD-1. Both cell populations showed reduced in vivo phagocytosis under PD-1 deficiency, and a cell transfer experiment revealed a more than 60% reduced postoperative ME infiltration of PD-1-deficient compared to wildtype controls. The primary PD-L1 source are infiltrating MDM, monocytes and neutrophils. Gene ontology (GO) analysis within the ME of PD-1-/- mice revealed lower enrichment levels of genes regulating metabolic respiratory chain processes, oxidative stress, and immune functions. Moreover, sorted CX3CR1+Ly6C+ MDMs of PD-1-/- mice showed stronger enrichment of genes associated with various immune functions, host defense and negative regulation of immune and neuronal cell death.
Conclusion: Our data provide new evidence on the role of PD-1 signaling in MDM during postoperative intestinal neuroinflammation following abdominal surgery. PD-1 deficiency prevents POI, results in a metabolic switch, and reduces infiltration capacity and phagocytosis of MDM. We conclude that interaction in PD-1 signaling might be a potential target in prevetion of POI or other immune-driven intestinal disorders.

Saturday
Society: AGA

Background: Postoperative ileus (POI) is a common consequence of abdominal surgery and a neuroinflammation-based disorder of the gastrointestinal tract, which results in motility disturbances compromising patients' recovery. The underlying neuroinflammation involves the activation of resident macrophages and monocyte-derived macrophages (MDM) infiltration into the intestine's muscularis externa (ME). Immune checkpoint proteins, including PD-1 and its ligands PD-L1 and PD-L2, play a prominent role in cancer immunology, but their role in non-oncological inflammation-driven diseases is still elusive. Herein, we studied the role of PD-1/PD-L1/PD-L2 signaling in POI.
Materials and methods: POI was induced by a surgical intestinal manipulation in wildtype, PD-1-/-, PD-L1-/- and PD-L2-/- mice. We performed flow cytometry to identify the cellular sources of PD-1 and PD-L1 and used a blood cell transfer model to determine the role of a leukocyte-restricted PD-1 deficiency. qPCR and SMART-Seq2 analyses were used to analyze transcriptomes of sorted CX3CR1GFP MDM from wildtype and PD-1-/- macrophage populations. Immunofluorescence microscopy visualized neuronal cell loss, PD-1 and PD-L2 expression and in vivo macrophage phagocytosis assay and GI transit measurements were used as functional readouts of PD-1 deficiency.
Results: PD-1, PD-L1 and PD-L2 mRNA levels were induced in the postoperative ME upon intestinal manipulation. PD-1-/- and PD-L1-/- but not PD-L2-/- mice were protected from POI- PD-1-/- mice showed a 50% reduction of MDM infiltration and reduced inflammation-mediated neuronal loss. Ly6C-Cx3CR1+ resident macrophages and Ly6C+Cx3CR1+ MDM were identified as the primary cellular source of PD-1. Both cell populations showed reduced in vivo phagocytosis under PD-1 deficiency, and a cell transfer experiment revealed a more than 60% reduced postoperative ME infiltration of PD-1-deficient compared to wildtype controls. The primary PD-L1 source are infiltrating MDM, monocytes and neutrophils. Gene ontology (GO) analysis within the ME of PD-1-/- mice revealed lower enrichment levels of genes regulating metabolic respiratory chain processes, oxidative stress, and immune functions. Moreover, sorted CX3CR1+Ly6C+ MDMs of PD-1-/- mice showed stronger enrichment of genes associated with various immune functions, host defense and negative regulation of immune and neuronal cell death.
Conclusion: Our data provide new evidence on the role of PD-1 signaling in MDM during postoperative intestinal neuroinflammation following abdominal surgery. PD-1 deficiency prevents POI, results in a metabolic switch, and reduces infiltration capacity and phagocytosis of MDM. We conclude that interaction in PD-1 signaling might be a potential target in prevetion of POI or other immune-driven intestinal disorders.
Pain is a cardinal sign of inflammation and is associated with flares in Inflammatory Bowel Disease (IBD) patients. It is commonly accepted that inflammatory mediators released by inflamed tissues and infiltrated inflammatory cells are responsible for activation of peripheral nociceptors and activation of pain pathways. However, 30% to 50% of IBD patients in remission still report significant pain, despite the absence of infiltrated inflammatory cells, complete repair of tissues and restoration of normal bowel habits. We hypothesized that histologically repaired tissues from patients in remission are releasing mediators that signal to sensory neurons and contribute to chronic pain symptoms. We aimed at understanding whether peripheral mediators present in colonic tissues of IBD patients in remission could contribute to the sensitization of peripheral nociceptors, thereby potentially activating pain pathways, and we investigated a potential role for Protease-Activated Receptor-1 (PAR1). Methods. IBD patients in remission or healthy control (HC) individuals (colon cancer screening presenting no pathology) had colonoscopy at the Gastroenterology Clinic of the Toulouse Hospital. Colon biopsies were harvested and freshly incubated in culture media for 1h. The obtained culture media were exposed to dorsal root ganglia (DRG) neurons primary cultures (either mouse DRG cultures or human DRG cultures obtained from brain-dead organ-donor patients at the Montpellier Hospital). Calcium signals in DRG neurons were recorded after their exposure to HC or IBD patient biopsy supernatants, in the presence or not of a PAR1 antagonist. Further, the effects of an oral treatment with a PAR1 antagonist (CVT120165) in a rat model of colitis induced by the intracolonic administration of trinitrobenzene sulfonic acid (TNBS) were investigated on abdominal nociceptive response to von Frey filament application and on tissue repair by histology scoring. Results. Colon biopsy supernatants from IBD patients in remission caused a significant increase in DRG neuron activation (both with mouse p<0.001, and human DRG neurons p<0.01), compared to the effects of HC biopsy supernatants. Pre-incubation of DRG neurons (both mouse or humans) with a PAR1 antagonist significantly inhibited IBD supernatants-induced DRG calcium signals. Oral treatment with the PAR1 antagonist CVT120165 significantly inhibited, in a dose-dependent manner, referred abdominal pain in rats 7-days after the induction of TNBS colitis, and also favored tissue repair. Conclusions. Peripheral mediators in the colon of IBD patients in remission activate sensory neurons by a PAR1-mediated mechanism. PAR1 blockade alleviates from pain symptoms in a rat model of colitis and helps tissue repair. Altogether, PAR1 appears as a good target for the treatment of IBD-associated pain in remission.

Saturday
Society: AGA

Background: Postoperative ileus (POI) is a common consequence of abdominal surgery and a neuroinflammation-based disorder of the gastrointestinal tract, which results in motility disturbances compromising patients' recovery. The underlying neuroinflammation involves the activation of resident macrophages and monocyte-derived macrophages (MDM) infiltration into the intestine's muscularis externa (ME). Immune checkpoint proteins, including PD-1 and its ligands PD-L1 and PD-L2, play a prominent role in cancer immunology, but their role in non-oncological inflammation-driven diseases is still elusive. Herein, we studied the role of PD-1/PD-L1/PD-L2 signaling in POI.
Materials and methods: POI was induced by a surgical intestinal manipulation in wildtype, PD-1-/-, PD-L1-/- and PD-L2-/- mice. We performed flow cytometry to identify the cellular sources of PD-1 and PD-L1 and used a blood cell transfer model to determine the role of a leukocyte-restricted PD-1 deficiency. qPCR and SMART-Seq2 analyses were used to analyze transcriptomes of sorted CX3CR1GFP MDM from wildtype and PD-1-/- macrophage populations. Immunofluorescence microscopy visualized neuronal cell loss, PD-1 and PD-L2 expression and in vivo macrophage phagocytosis assay and GI transit measurements were used as functional readouts of PD-1 deficiency.
Results: PD-1, PD-L1 and PD-L2 mRNA levels were induced in the postoperative ME upon intestinal manipulation. PD-1-/- and PD-L1-/- but not PD-L2-/- mice were protected from POI- PD-1-/- mice showed a 50% reduction of MDM infiltration and reduced inflammation-mediated neuronal loss. Ly6C-Cx3CR1+ resident macrophages and Ly6C+Cx3CR1+ MDM were identified as the primary cellular source of PD-1. Both cell populations showed reduced in vivo phagocytosis under PD-1 deficiency, and a cell transfer experiment revealed a more than 60% reduced postoperative ME infiltration of PD-1-deficient compared to wildtype controls. The primary PD-L1 source are infiltrating MDM, monocytes and neutrophils. Gene ontology (GO) analysis within the ME of PD-1-/- mice revealed lower enrichment levels of genes regulating metabolic respiratory chain processes, oxidative stress, and immune functions. Moreover, sorted CX3CR1+Ly6C+ MDMs of PD-1-/- mice showed stronger enrichment of genes associated with various immune functions, host defense and negative regulation of immune and neuronal cell death.
Conclusion: Our data provide new evidence on the role of PD-1 signaling in MDM during postoperative intestinal neuroinflammation following abdominal surgery. PD-1 deficiency prevents POI, results in a metabolic switch, and reduces infiltration capacity and phagocytosis of MDM. We conclude that interaction in PD-1 signaling might be a potential target in prevetion of POI or other immune-driven intestinal disorders.
Pain is a cardinal sign of inflammation and is associated with flares in Inflammatory Bowel Disease (IBD) patients. It is commonly accepted that inflammatory mediators released by inflamed tissues and infiltrated inflammatory cells are responsible for activation of peripheral nociceptors and activation of pain pathways. However, 30% to 50% of IBD patients in remission still report significant pain, despite the absence of infiltrated inflammatory cells, complete repair of tissues and restoration of normal bowel habits. We hypothesized that histologically repaired tissues from patients in remission are releasing mediators that signal to sensory neurons and contribute to chronic pain symptoms. We aimed at understanding whether peripheral mediators present in colonic tissues of IBD patients in remission could contribute to the sensitization of peripheral nociceptors, thereby potentially activating pain pathways, and we investigated a potential role for Protease-Activated Receptor-1 (PAR1). Methods. IBD patients in remission or healthy control (HC) individuals (colon cancer screening presenting no pathology) had colonoscopy at the Gastroenterology Clinic of the Toulouse Hospital. Colon biopsies were harvested and freshly incubated in culture media for 1h. The obtained culture media were exposed to dorsal root ganglia (DRG) neurons primary cultures (either mouse DRG cultures or human DRG cultures obtained from brain-dead organ-donor patients at the Montpellier Hospital). Calcium signals in DRG neurons were recorded after their exposure to HC or IBD patient biopsy supernatants, in the presence or not of a PAR1 antagonist. Further, the effects of an oral treatment with a PAR1 antagonist (CVT120165) in a rat model of colitis induced by the intracolonic administration of trinitrobenzene sulfonic acid (TNBS) were investigated on abdominal nociceptive response to von Frey filament application and on tissue repair by histology scoring. Results. Colon biopsy supernatants from IBD patients in remission caused a significant increase in DRG neuron activation (both with mouse p<0.001, and human DRG neurons p<0.01), compared to the effects of HC biopsy supernatants. Pre-incubation of DRG neurons (both mouse or humans) with a PAR1 antagonist significantly inhibited IBD supernatants-induced DRG calcium signals. Oral treatment with the PAR1 antagonist CVT120165 significantly inhibited, in a dose-dependent manner, referred abdominal pain in rats 7-days after the induction of TNBS colitis, and also favored tissue repair. Conclusions. Peripheral mediators in the colon of IBD patients in remission activate sensory neurons by a PAR1-mediated mechanism. PAR1 blockade alleviates from pain symptoms in a rat model of colitis and helps tissue repair. Altogether, PAR1 appears as a good target for the treatment of IBD-associated pain in remission.
Background: The current prevalent paradigm focuses on small intestinal (SI) bacterial overgrowth (SIBO) as a cause of gastrointestinal (GI) symptoms, such as abdominal pain. However, recent studies have found that alterations in SI microbial composition rather than SIBO may underlie GI symptoms commonly seen in patients with disorders of gut-brain axis interaction. Human stool is commonly used to recapitulate the human gut microbiome in germ free (GF) mice. Stool contains bacteria from the entire GI tract, and while stool faithfully captures colonic bacteria, it remains unclear if stool can also recapitulate the SI microbiome in mice.
Aim: To establish a mouse model that replicates the human SI microbiome and investigate the influence of the human SI microbiome on visceral sensitivity.
Methods: Duodenal aspirate and stool samples were collected from healthy controls (HC) and age/sex matched patients with abdominal pain (SIBO and bacterial pathogen culture negative). GF mice were gavaged with human SI aspirate or stool and were maintained in gnotobiotic isolators or ISOcage™ system. After 4 weeks, SI contents from mice were collected and processed with the original human input samples (SI aspirate or stool) for 16S rRNA sequencing. In a subset of mice, visceromotor response (VMR) to colorectal balloon distension (CRD) was measured during 10-second distension intervals of 15, 30, 45 and 60 mmHg using a solid-state manometry catheter in the colon.
Results: To determine the input sample that best recapitulates the human SI microbiome, we compared the mouse and human SI microbiome following colonization of GF mice with human SI contents or stool (n=3 donors, 3-4 mice/donor). β-diversity-based principal coordinate analysis showed that the SI microbiome of mice, colonized with human SI aspirate, more closely resembled the human input sample (80% of human SI species were present in mouse SI) than the SI microbiome of mice, colonized with human stool (40% of species were retrieved) (Fig. 1). Hence, we colonized GF mice (4-12 mice/donor, 50% males) with SI contents from HC (n=3) or patients with abdominal pain (n=2) to study the effect of SI microbiome on GI physiology. Post-colonization, mice with SI contents from patients had significantly higher VMR to CRD when compared to mice colonized with SI aspirates from HC (Fig. 2). We sequenced human and mouse SI contents from 1 abdominal pain patient and 2 HCs and found a Shigella spp. in the human and mouse SI content from the patient. The relative abundance of Shigella spp. in the mouse SI positively correlated with the VMR to CRD (ρ=0.86, p<0.001).
Conclusion: Human SI contents are better than stool for replicating the human SI microbiome in mice. The presence of Shigella spp. in the SI may underlie visceral hypersensitivity in patients with abdominal pain and represents an important therapeutic target.
<b>Figure 1.</b> Beta diversity-based principal coordinate analysis of SI contents of mice gavaged with human SI aspirates (purple) and human stool (yellow) and the original human input sample (human SI, green and human stool, grey).

Figure 1. Beta diversity-based principal coordinate analysis of SI contents of mice gavaged with human SI aspirates (purple) and human stool (yellow) and the original human input sample (human SI, green and human stool, grey).

<b>Figure 2.</b> SI dysbiosis induces visceral hypersensitivity. The visceromotor response of mice, gavaged with SI aspirates from patients with abdominal pain, was increased at distension pressures of 30, 45 and 60 mmHg when compared to mice, gavaged with SI aspirates from healthy controls. Repeated measurements Two-Way ANOVA with Bonferroni post-hoc correction to account for multiple mice colonized with the same donor sample: *p<0.05, **p<0.01.

Figure 2. SI dysbiosis induces visceral hypersensitivity. The visceromotor response of mice, gavaged with SI aspirates from patients with abdominal pain, was increased at distension pressures of 30, 45 and 60 mmHg when compared to mice, gavaged with SI aspirates from healthy controls. Repeated measurements Two-Way ANOVA with Bonferroni post-hoc correction to account for multiple mice colonized with the same donor sample: *p<0.05, **p<0.01.


Saturday
Society: AGA

Background: Postoperative ileus (POI) is a common consequence of abdominal surgery and a neuroinflammation-based disorder of the gastrointestinal tract, which results in motility disturbances compromising patients' recovery. The underlying neuroinflammation involves the activation of resident macrophages and monocyte-derived macrophages (MDM) infiltration into the intestine's muscularis externa (ME). Immune checkpoint proteins, including PD-1 and its ligands PD-L1 and PD-L2, play a prominent role in cancer immunology, but their role in non-oncological inflammation-driven diseases is still elusive. Herein, we studied the role of PD-1/PD-L1/PD-L2 signaling in POI.
Materials and methods: POI was induced by a surgical intestinal manipulation in wildtype, PD-1-/-, PD-L1-/- and PD-L2-/- mice. We performed flow cytometry to identify the cellular sources of PD-1 and PD-L1 and used a blood cell transfer model to determine the role of a leukocyte-restricted PD-1 deficiency. qPCR and SMART-Seq2 analyses were used to analyze transcriptomes of sorted CX3CR1GFP MDM from wildtype and PD-1-/- macrophage populations. Immunofluorescence microscopy visualized neuronal cell loss, PD-1 and PD-L2 expression and in vivo macrophage phagocytosis assay and GI transit measurements were used as functional readouts of PD-1 deficiency.
Results: PD-1, PD-L1 and PD-L2 mRNA levels were induced in the postoperative ME upon intestinal manipulation. PD-1-/- and PD-L1-/- but not PD-L2-/- mice were protected from POI- PD-1-/- mice showed a 50% reduction of MDM infiltration and reduced inflammation-mediated neuronal loss. Ly6C-Cx3CR1+ resident macrophages and Ly6C+Cx3CR1+ MDM were identified as the primary cellular source of PD-1. Both cell populations showed reduced in vivo phagocytosis under PD-1 deficiency, and a cell transfer experiment revealed a more than 60% reduced postoperative ME infiltration of PD-1-deficient compared to wildtype controls. The primary PD-L1 source are infiltrating MDM, monocytes and neutrophils. Gene ontology (GO) analysis within the ME of PD-1-/- mice revealed lower enrichment levels of genes regulating metabolic respiratory chain processes, oxidative stress, and immune functions. Moreover, sorted CX3CR1+Ly6C+ MDMs of PD-1-/- mice showed stronger enrichment of genes associated with various immune functions, host defense and negative regulation of immune and neuronal cell death.
Conclusion: Our data provide new evidence on the role of PD-1 signaling in MDM during postoperative intestinal neuroinflammation following abdominal surgery. PD-1 deficiency prevents POI, results in a metabolic switch, and reduces infiltration capacity and phagocytosis of MDM. We conclude that interaction in PD-1 signaling might be a potential target in prevetion of POI or other immune-driven intestinal disorders.
Pain is a cardinal sign of inflammation and is associated with flares in Inflammatory Bowel Disease (IBD) patients. It is commonly accepted that inflammatory mediators released by inflamed tissues and infiltrated inflammatory cells are responsible for activation of peripheral nociceptors and activation of pain pathways. However, 30% to 50% of IBD patients in remission still report significant pain, despite the absence of infiltrated inflammatory cells, complete repair of tissues and restoration of normal bowel habits. We hypothesized that histologically repaired tissues from patients in remission are releasing mediators that signal to sensory neurons and contribute to chronic pain symptoms. We aimed at understanding whether peripheral mediators present in colonic tissues of IBD patients in remission could contribute to the sensitization of peripheral nociceptors, thereby potentially activating pain pathways, and we investigated a potential role for Protease-Activated Receptor-1 (PAR1). Methods. IBD patients in remission or healthy control (HC) individuals (colon cancer screening presenting no pathology) had colonoscopy at the Gastroenterology Clinic of the Toulouse Hospital. Colon biopsies were harvested and freshly incubated in culture media for 1h. The obtained culture media were exposed to dorsal root ganglia (DRG) neurons primary cultures (either mouse DRG cultures or human DRG cultures obtained from brain-dead organ-donor patients at the Montpellier Hospital). Calcium signals in DRG neurons were recorded after their exposure to HC or IBD patient biopsy supernatants, in the presence or not of a PAR1 antagonist. Further, the effects of an oral treatment with a PAR1 antagonist (CVT120165) in a rat model of colitis induced by the intracolonic administration of trinitrobenzene sulfonic acid (TNBS) were investigated on abdominal nociceptive response to von Frey filament application and on tissue repair by histology scoring. Results. Colon biopsy supernatants from IBD patients in remission caused a significant increase in DRG neuron activation (both with mouse p<0.001, and human DRG neurons p<0.01), compared to the effects of HC biopsy supernatants. Pre-incubation of DRG neurons (both mouse or humans) with a PAR1 antagonist significantly inhibited IBD supernatants-induced DRG calcium signals. Oral treatment with the PAR1 antagonist CVT120165 significantly inhibited, in a dose-dependent manner, referred abdominal pain in rats 7-days after the induction of TNBS colitis, and also favored tissue repair. Conclusions. Peripheral mediators in the colon of IBD patients in remission activate sensory neurons by a PAR1-mediated mechanism. PAR1 blockade alleviates from pain symptoms in a rat model of colitis and helps tissue repair. Altogether, PAR1 appears as a good target for the treatment of IBD-associated pain in remission.
Background: The current prevalent paradigm focuses on small intestinal (SI) bacterial overgrowth (SIBO) as a cause of gastrointestinal (GI) symptoms, such as abdominal pain. However, recent studies have found that alterations in SI microbial composition rather than SIBO may underlie GI symptoms commonly seen in patients with disorders of gut-brain axis interaction. Human stool is commonly used to recapitulate the human gut microbiome in germ free (GF) mice. Stool contains bacteria from the entire GI tract, and while stool faithfully captures colonic bacteria, it remains unclear if stool can also recapitulate the SI microbiome in mice.
Aim: To establish a mouse model that replicates the human SI microbiome and investigate the influence of the human SI microbiome on visceral sensitivity.
Methods: Duodenal aspirate and stool samples were collected from healthy controls (HC) and age/sex matched patients with abdominal pain (SIBO and bacterial pathogen culture negative). GF mice were gavaged with human SI aspirate or stool and were maintained in gnotobiotic isolators or ISOcage™ system. After 4 weeks, SI contents from mice were collected and processed with the original human input samples (SI aspirate or stool) for 16S rRNA sequencing. In a subset of mice, visceromotor response (VMR) to colorectal balloon distension (CRD) was measured during 10-second distension intervals of 15, 30, 45 and 60 mmHg using a solid-state manometry catheter in the colon.
Results: To determine the input sample that best recapitulates the human SI microbiome, we compared the mouse and human SI microbiome following colonization of GF mice with human SI contents or stool (n=3 donors, 3-4 mice/donor). β-diversity-based principal coordinate analysis showed that the SI microbiome of mice, colonized with human SI aspirate, more closely resembled the human input sample (80% of human SI species were present in mouse SI) than the SI microbiome of mice, colonized with human stool (40% of species were retrieved) (Fig. 1). Hence, we colonized GF mice (4-12 mice/donor, 50% males) with SI contents from HC (n=3) or patients with abdominal pain (n=2) to study the effect of SI microbiome on GI physiology. Post-colonization, mice with SI contents from patients had significantly higher VMR to CRD when compared to mice colonized with SI aspirates from HC (Fig. 2). We sequenced human and mouse SI contents from 1 abdominal pain patient and 2 HCs and found a Shigella spp. in the human and mouse SI content from the patient. The relative abundance of Shigella spp. in the mouse SI positively correlated with the VMR to CRD (ρ=0.86, p<0.001).
Conclusion: Human SI contents are better than stool for replicating the human SI microbiome in mice. The presence of Shigella spp. in the SI may underlie visceral hypersensitivity in patients with abdominal pain and represents an important therapeutic target.
<b>Figure 1.</b> Beta diversity-based principal coordinate analysis of SI contents of mice gavaged with human SI aspirates (purple) and human stool (yellow) and the original human input sample (human SI, green and human stool, grey).

Figure 1. Beta diversity-based principal coordinate analysis of SI contents of mice gavaged with human SI aspirates (purple) and human stool (yellow) and the original human input sample (human SI, green and human stool, grey).

<b>Figure 2.</b> SI dysbiosis induces visceral hypersensitivity. The visceromotor response of mice, gavaged with SI aspirates from patients with abdominal pain, was increased at distension pressures of 30, 45 and 60 mmHg when compared to mice, gavaged with SI aspirates from healthy controls. Repeated measurements Two-Way ANOVA with Bonferroni post-hoc correction to account for multiple mice colonized with the same donor sample: *p<0.05, **p<0.01.

Figure 2. SI dysbiosis induces visceral hypersensitivity. The visceromotor response of mice, gavaged with SI aspirates from patients with abdominal pain, was increased at distension pressures of 30, 45 and 60 mmHg when compared to mice, gavaged with SI aspirates from healthy controls. Repeated measurements Two-Way ANOVA with Bonferroni post-hoc correction to account for multiple mice colonized with the same donor sample: *p<0.05, **p<0.01.

Background: We recently showed that splanchnic nerve plays a key role in normal physiology of energy regulation and post-gastric bypass (RYGB), where its activity is significantly increased to induce “browning” of mesenteric fat. Administration of an endocannabinoid receptor-1 (CB1) inverse agonist (Rimonabant) increased splanchnic nerve activity and replicated an energy balance phenotype in mice that similar to that induced by RYGB. We also showed that splanchnic denervation significantly reduces the response to Rimonabant. Methods: We explored : 1) where these peripheral CB1 are located in the gut and how do they mediate their energy regulatory effects using surgical mouse models. 2) whether gut microbiome changes post-gastric bypass mediate the energy effect of the surgery through the CB1-expressing cells. Results: We found that intestinal CB1 co-localizes mainly with CGRP-expressing cells (sensory neurons) and not epithelial, enteroendocrine or immune cells (Figure 1). We then developed and confirmed a model of afferent selective denervation (aSpDNV) using topical capsaicin over celiac ganglia and its branches. Interestingly, aSpDNV mice express a phase of increase food intake but no change in body weight. Furthermore, fecal microbial transfer from RYGB and Sham -operated mice into naïf recipients induces a significant increase in afferent and efferent splanchnic nerve activity of RYGB-stool recipients compared to their controls (Figure 2). Finally, intestinal CB1 expression was significantly lower in RYGB-stool recipients compared to their controls. Conclusion: Gut microbiome can communicate energy signals directly to the brain through CB1-expressing sensory neurons.

Saturday
Society: AGA

Background: Postoperative ileus (POI) is a common consequence of abdominal surgery and a neuroinflammation-based disorder of the gastrointestinal tract, which results in motility disturbances compromising patients' recovery. The underlying neuroinflammation involves the activation of resident macrophages and monocyte-derived macrophages (MDM) infiltration into the intestine's muscularis externa (ME). Immune checkpoint proteins, including PD-1 and its ligands PD-L1 and PD-L2, play a prominent role in cancer immunology, but their role in non-oncological inflammation-driven diseases is still elusive. Herein, we studied the role of PD-1/PD-L1/PD-L2 signaling in POI.
Materials and methods: POI was induced by a surgical intestinal manipulation in wildtype, PD-1-/-, PD-L1-/- and PD-L2-/- mice. We performed flow cytometry to identify the cellular sources of PD-1 and PD-L1 and used a blood cell transfer model to determine the role of a leukocyte-restricted PD-1 deficiency. qPCR and SMART-Seq2 analyses were used to analyze transcriptomes of sorted CX3CR1GFP MDM from wildtype and PD-1-/- macrophage populations. Immunofluorescence microscopy visualized neuronal cell loss, PD-1 and PD-L2 expression and in vivo macrophage phagocytosis assay and GI transit measurements were used as functional readouts of PD-1 deficiency.
Results: PD-1, PD-L1 and PD-L2 mRNA levels were induced in the postoperative ME upon intestinal manipulation. PD-1-/- and PD-L1-/- but not PD-L2-/- mice were protected from POI- PD-1-/- mice showed a 50% reduction of MDM infiltration and reduced inflammation-mediated neuronal loss. Ly6C-Cx3CR1+ resident macrophages and Ly6C+Cx3CR1+ MDM were identified as the primary cellular source of PD-1. Both cell populations showed reduced in vivo phagocytosis under PD-1 deficiency, and a cell transfer experiment revealed a more than 60% reduced postoperative ME infiltration of PD-1-deficient compared to wildtype controls. The primary PD-L1 source are infiltrating MDM, monocytes and neutrophils. Gene ontology (GO) analysis within the ME of PD-1-/- mice revealed lower enrichment levels of genes regulating metabolic respiratory chain processes, oxidative stress, and immune functions. Moreover, sorted CX3CR1+Ly6C+ MDMs of PD-1-/- mice showed stronger enrichment of genes associated with various immune functions, host defense and negative regulation of immune and neuronal cell death.
Conclusion: Our data provide new evidence on the role of PD-1 signaling in MDM during postoperative intestinal neuroinflammation following abdominal surgery. PD-1 deficiency prevents POI, results in a metabolic switch, and reduces infiltration capacity and phagocytosis of MDM. We conclude that interaction in PD-1 signaling might be a potential target in prevetion of POI or other immune-driven intestinal disorders.
Pain is a cardinal sign of inflammation and is associated with flares in Inflammatory Bowel Disease (IBD) patients. It is commonly accepted that inflammatory mediators released by inflamed tissues and infiltrated inflammatory cells are responsible for activation of peripheral nociceptors and activation of pain pathways. However, 30% to 50% of IBD patients in remission still report significant pain, despite the absence of infiltrated inflammatory cells, complete repair of tissues and restoration of normal bowel habits. We hypothesized that histologically repaired tissues from patients in remission are releasing mediators that signal to sensory neurons and contribute to chronic pain symptoms. We aimed at understanding whether peripheral mediators present in colonic tissues of IBD patients in remission could contribute to the sensitization of peripheral nociceptors, thereby potentially activating pain pathways, and we investigated a potential role for Protease-Activated Receptor-1 (PAR1). Methods. IBD patients in remission or healthy control (HC) individuals (colon cancer screening presenting no pathology) had colonoscopy at the Gastroenterology Clinic of the Toulouse Hospital. Colon biopsies were harvested and freshly incubated in culture media for 1h. The obtained culture media were exposed to dorsal root ganglia (DRG) neurons primary cultures (either mouse DRG cultures or human DRG cultures obtained from brain-dead organ-donor patients at the Montpellier Hospital). Calcium signals in DRG neurons were recorded after their exposure to HC or IBD patient biopsy supernatants, in the presence or not of a PAR1 antagonist. Further, the effects of an oral treatment with a PAR1 antagonist (CVT120165) in a rat model of colitis induced by the intracolonic administration of trinitrobenzene sulfonic acid (TNBS) were investigated on abdominal nociceptive response to von Frey filament application and on tissue repair by histology scoring. Results. Colon biopsy supernatants from IBD patients in remission caused a significant increase in DRG neuron activation (both with mouse p<0.001, and human DRG neurons p<0.01), compared to the effects of HC biopsy supernatants. Pre-incubation of DRG neurons (both mouse or humans) with a PAR1 antagonist significantly inhibited IBD supernatants-induced DRG calcium signals. Oral treatment with the PAR1 antagonist CVT120165 significantly inhibited, in a dose-dependent manner, referred abdominal pain in rats 7-days after the induction of TNBS colitis, and also favored tissue repair. Conclusions. Peripheral mediators in the colon of IBD patients in remission activate sensory neurons by a PAR1-mediated mechanism. PAR1 blockade alleviates from pain symptoms in a rat model of colitis and helps tissue repair. Altogether, PAR1 appears as a good target for the treatment of IBD-associated pain in remission.
Background: The current prevalent paradigm focuses on small intestinal (SI) bacterial overgrowth (SIBO) as a cause of gastrointestinal (GI) symptoms, such as abdominal pain. However, recent studies have found that alterations in SI microbial composition rather than SIBO may underlie GI symptoms commonly seen in patients with disorders of gut-brain axis interaction. Human stool is commonly used to recapitulate the human gut microbiome in germ free (GF) mice. Stool contains bacteria from the entire GI tract, and while stool faithfully captures colonic bacteria, it remains unclear if stool can also recapitulate the SI microbiome in mice.
Aim: To establish a mouse model that replicates the human SI microbiome and investigate the influence of the human SI microbiome on visceral sensitivity.
Methods: Duodenal aspirate and stool samples were collected from healthy controls (HC) and age/sex matched patients with abdominal pain (SIBO and bacterial pathogen culture negative). GF mice were gavaged with human SI aspirate or stool and were maintained in gnotobiotic isolators or ISOcage™ system. After 4 weeks, SI contents from mice were collected and processed with the original human input samples (SI aspirate or stool) for 16S rRNA sequencing. In a subset of mice, visceromotor response (VMR) to colorectal balloon distension (CRD) was measured during 10-second distension intervals of 15, 30, 45 and 60 mmHg using a solid-state manometry catheter in the colon.
Results: To determine the input sample that best recapitulates the human SI microbiome, we compared the mouse and human SI microbiome following colonization of GF mice with human SI contents or stool (n=3 donors, 3-4 mice/donor). β-diversity-based principal coordinate analysis showed that the SI microbiome of mice, colonized with human SI aspirate, more closely resembled the human input sample (80% of human SI species were present in mouse SI) than the SI microbiome of mice, colonized with human stool (40% of species were retrieved) (Fig. 1). Hence, we colonized GF mice (4-12 mice/donor, 50% males) with SI contents from HC (n=3) or patients with abdominal pain (n=2) to study the effect of SI microbiome on GI physiology. Post-colonization, mice with SI contents from patients had significantly higher VMR to CRD when compared to mice colonized with SI aspirates from HC (Fig. 2). We sequenced human and mouse SI contents from 1 abdominal pain patient and 2 HCs and found a Shigella spp. in the human and mouse SI content from the patient. The relative abundance of Shigella spp. in the mouse SI positively correlated with the VMR to CRD (ρ=0.86, p<0.001).
Conclusion: Human SI contents are better than stool for replicating the human SI microbiome in mice. The presence of Shigella spp. in the SI may underlie visceral hypersensitivity in patients with abdominal pain and represents an important therapeutic target.
<b>Figure 1.</b> Beta diversity-based principal coordinate analysis of SI contents of mice gavaged with human SI aspirates (purple) and human stool (yellow) and the original human input sample (human SI, green and human stool, grey).

Figure 1. Beta diversity-based principal coordinate analysis of SI contents of mice gavaged with human SI aspirates (purple) and human stool (yellow) and the original human input sample (human SI, green and human stool, grey).

<b>Figure 2.</b> SI dysbiosis induces visceral hypersensitivity. The visceromotor response of mice, gavaged with SI aspirates from patients with abdominal pain, was increased at distension pressures of 30, 45 and 60 mmHg when compared to mice, gavaged with SI aspirates from healthy controls. Repeated measurements Two-Way ANOVA with Bonferroni post-hoc correction to account for multiple mice colonized with the same donor sample: *p<0.05, **p<0.01.

Figure 2. SI dysbiosis induces visceral hypersensitivity. The visceromotor response of mice, gavaged with SI aspirates from patients with abdominal pain, was increased at distension pressures of 30, 45 and 60 mmHg when compared to mice, gavaged with SI aspirates from healthy controls. Repeated measurements Two-Way ANOVA with Bonferroni post-hoc correction to account for multiple mice colonized with the same donor sample: *p<0.05, **p<0.01.

Background: We recently showed that splanchnic nerve plays a key role in normal physiology of energy regulation and post-gastric bypass (RYGB), where its activity is significantly increased to induce “browning” of mesenteric fat. Administration of an endocannabinoid receptor-1 (CB1) inverse agonist (Rimonabant) increased splanchnic nerve activity and replicated an energy balance phenotype in mice that similar to that induced by RYGB. We also showed that splanchnic denervation significantly reduces the response to Rimonabant. Methods: We explored : 1) where these peripheral CB1 are located in the gut and how do they mediate their energy regulatory effects using surgical mouse models. 2) whether gut microbiome changes post-gastric bypass mediate the energy effect of the surgery through the CB1-expressing cells. Results: We found that intestinal CB1 co-localizes mainly with CGRP-expressing cells (sensory neurons) and not epithelial, enteroendocrine or immune cells (Figure 1). We then developed and confirmed a model of afferent selective denervation (aSpDNV) using topical capsaicin over celiac ganglia and its branches. Interestingly, aSpDNV mice express a phase of increase food intake but no change in body weight. Furthermore, fecal microbial transfer from RYGB and Sham -operated mice into naïf recipients induces a significant increase in afferent and efferent splanchnic nerve activity of RYGB-stool recipients compared to their controls (Figure 2). Finally, intestinal CB1 expression was significantly lower in RYGB-stool recipients compared to their controls. Conclusion: Gut microbiome can communicate energy signals directly to the brain through CB1-expressing sensory neurons.
BACKGROUND: Modern techniques allow specific target of glial subtypes to examine their roles in visceral hypersensitivity and pain. Satellite glial cells (SGCs) intimately interact with sensory neurons in dorsal root ganglia (DRG), however, their specific roles in regulating DRG neuron activity in intact animals in influencing colonic sensitivity and pain behaviors are not characterized. AIMS: (1) To examine the effects of cell-targeted activation of SGCs on sensory neuron activity/excitability, and (2) to characterize the functional role of SGCs in regulation of colonic mechanosensitivity and pain. METHODS: Using cre-loxP technique to specifically activate SGCs by expressing hM3Dq in proteolipid protein (PLP)- or glial fibrillary acidic protein (GFAP)-expressing cells followed by clozapine N-oxide (CNO, 1-2 mg/kg intraperitoneally (i.p.) or 26 µM intrathecally (i.t.)) treatment. The number of hM3Dq-expressing SGCs is measured by flow cytometry. The activity/excitability of mechanosensory neurons were assessed by electroimaging responding to glass pipette poking or shear stress along with D-GsMtx4, a PIEZO2 inhibitor (10 µM). Colonic mechanosensing was measured by colonometry. Pain behaviors were assessed by hindpaw withdrawal responses to Von-Frey stimulation, hot plate, and gait assay(s). Calcitonin gene-related peptide (CGRP) expression was examined by immunohistochemistry/slot blot. Neurogenic inflammation was assessed by H&E stain. RESULTS: Chemogenetic activation of SGCs (i.p.) induced colonic hypersensitivity and somatic mechanical pain in male but not female mice (n>3; p<0.05), with no change in thermal sensitivity in either sex. hM3Dq expression was strongly present in SGCs of DRG with higher levels in male than female mice (p<0.05), some in hindpaw, and none in the colon or spinal cord of both sexes. Activation of SGCs also increased CGRP levels in DRG neurons (3.5-fold, p<0.05), adjacent to activated SGCs, and in spinal dorsal horn extending to the central commissure in male mice but not female mice, enhanced the activity/excitability of mechanosensory DRG neurons (38/55 (69%) vs 9/23 (39% in control) responding to poking; 260/330 neurons (79%) vs 77/280 (28% in control) responding to shear), and induced neurogenic inflammation in the hindpaw and colon. Results from i.t. CNO-treated Plp;hM3Dq mice and i.p. CNO-treated GFAP;hM3Dq mice recapitulated the behavioral and molecular results in i.p. CNO-treated PLP;hM3Dq mice. CONCLUSION: The augmentation in colonic mechanical sensitivity, somatic mechanical pain, CGRP expression in DRG neurons in male mice but not female mice following SGC activation suggest a sexual dimorphic role of SGCs in regulation of visceral hypersensitivity and pain. Elevation in the activity/excitability of mechanosensory neurons after SGC activation reveal an SGC-mechanosensory neuron crosstalk in pain processing.

Saturday
Society: AGA

Background: Postoperative ileus (POI) is a common consequence of abdominal surgery and a neuroinflammation-based disorder of the gastrointestinal tract, which results in motility disturbances compromising patients' recovery. The underlying neuroinflammation involves the activation of resident macrophages and monocyte-derived macrophages (MDM) infiltration into the intestine's muscularis externa (ME). Immune checkpoint proteins, including PD-1 and its ligands PD-L1 and PD-L2, play a prominent role in cancer immunology, but their role in non-oncological inflammation-driven diseases is still elusive. Herein, we studied the role of PD-1/PD-L1/PD-L2 signaling in POI.
Materials and methods: POI was induced by a surgical intestinal manipulation in wildtype, PD-1-/-, PD-L1-/- and PD-L2-/- mice. We performed flow cytometry to identify the cellular sources of PD-1 and PD-L1 and used a blood cell transfer model to determine the role of a leukocyte-restricted PD-1 deficiency. qPCR and SMART-Seq2 analyses were used to analyze transcriptomes of sorted CX3CR1GFP MDM from wildtype and PD-1-/- macrophage populations. Immunofluorescence microscopy visualized neuronal cell loss, PD-1 and PD-L2 expression and in vivo macrophage phagocytosis assay and GI transit measurements were used as functional readouts of PD-1 deficiency.
Results: PD-1, PD-L1 and PD-L2 mRNA levels were induced in the postoperative ME upon intestinal manipulation. PD-1-/- and PD-L1-/- but not PD-L2-/- mice were protected from POI- PD-1-/- mice showed a 50% reduction of MDM infiltration and reduced inflammation-mediated neuronal loss. Ly6C-Cx3CR1+ resident macrophages and Ly6C+Cx3CR1+ MDM were identified as the primary cellular source of PD-1. Both cell populations showed reduced in vivo phagocytosis under PD-1 deficiency, and a cell transfer experiment revealed a more than 60% reduced postoperative ME infiltration of PD-1-deficient compared to wildtype controls. The primary PD-L1 source are infiltrating MDM, monocytes and neutrophils. Gene ontology (GO) analysis within the ME of PD-1-/- mice revealed lower enrichment levels of genes regulating metabolic respiratory chain processes, oxidative stress, and immune functions. Moreover, sorted CX3CR1+Ly6C+ MDMs of PD-1-/- mice showed stronger enrichment of genes associated with various immune functions, host defense and negative regulation of immune and neuronal cell death.
Conclusion: Our data provide new evidence on the role of PD-1 signaling in MDM during postoperative intestinal neuroinflammation following abdominal surgery. PD-1 deficiency prevents POI, results in a metabolic switch, and reduces infiltration capacity and phagocytosis of MDM. We conclude that interaction in PD-1 signaling might be a potential target in prevetion of POI or other immune-driven intestinal disorders.
Pain is a cardinal sign of inflammation and is associated with flares in Inflammatory Bowel Disease (IBD) patients. It is commonly accepted that inflammatory mediators released by inflamed tissues and infiltrated inflammatory cells are responsible for activation of peripheral nociceptors and activation of pain pathways. However, 30% to 50% of IBD patients in remission still report significant pain, despite the absence of infiltrated inflammatory cells, complete repair of tissues and restoration of normal bowel habits. We hypothesized that histologically repaired tissues from patients in remission are releasing mediators that signal to sensory neurons and contribute to chronic pain symptoms. We aimed at understanding whether peripheral mediators present in colonic tissues of IBD patients in remission could contribute to the sensitization of peripheral nociceptors, thereby potentially activating pain pathways, and we investigated a potential role for Protease-Activated Receptor-1 (PAR1). Methods. IBD patients in remission or healthy control (HC) individuals (colon cancer screening presenting no pathology) had colonoscopy at the Gastroenterology Clinic of the Toulouse Hospital. Colon biopsies were harvested and freshly incubated in culture media for 1h. The obtained culture media were exposed to dorsal root ganglia (DRG) neurons primary cultures (either mouse DRG cultures or human DRG cultures obtained from brain-dead organ-donor patients at the Montpellier Hospital). Calcium signals in DRG neurons were recorded after their exposure to HC or IBD patient biopsy supernatants, in the presence or not of a PAR1 antagonist. Further, the effects of an oral treatment with a PAR1 antagonist (CVT120165) in a rat model of colitis induced by the intracolonic administration of trinitrobenzene sulfonic acid (TNBS) were investigated on abdominal nociceptive response to von Frey filament application and on tissue repair by histology scoring. Results. Colon biopsy supernatants from IBD patients in remission caused a significant increase in DRG neuron activation (both with mouse p<0.001, and human DRG neurons p<0.01), compared to the effects of HC biopsy supernatants. Pre-incubation of DRG neurons (both mouse or humans) with a PAR1 antagonist significantly inhibited IBD supernatants-induced DRG calcium signals. Oral treatment with the PAR1 antagonist CVT120165 significantly inhibited, in a dose-dependent manner, referred abdominal pain in rats 7-days after the induction of TNBS colitis, and also favored tissue repair. Conclusions. Peripheral mediators in the colon of IBD patients in remission activate sensory neurons by a PAR1-mediated mechanism. PAR1 blockade alleviates from pain symptoms in a rat model of colitis and helps tissue repair. Altogether, PAR1 appears as a good target for the treatment of IBD-associated pain in remission.
Background: The current prevalent paradigm focuses on small intestinal (SI) bacterial overgrowth (SIBO) as a cause of gastrointestinal (GI) symptoms, such as abdominal pain. However, recent studies have found that alterations in SI microbial composition rather than SIBO may underlie GI symptoms commonly seen in patients with disorders of gut-brain axis interaction. Human stool is commonly used to recapitulate the human gut microbiome in germ free (GF) mice. Stool contains bacteria from the entire GI tract, and while stool faithfully captures colonic bacteria, it remains unclear if stool can also recapitulate the SI microbiome in mice.
Aim: To establish a mouse model that replicates the human SI microbiome and investigate the influence of the human SI microbiome on visceral sensitivity.
Methods: Duodenal aspirate and stool samples were collected from healthy controls (HC) and age/sex matched patients with abdominal pain (SIBO and bacterial pathogen culture negative). GF mice were gavaged with human SI aspirate or stool and were maintained in gnotobiotic isolators or ISOcage™ system. After 4 weeks, SI contents from mice were collected and processed with the original human input samples (SI aspirate or stool) for 16S rRNA sequencing. In a subset of mice, visceromotor response (VMR) to colorectal balloon distension (CRD) was measured during 10-second distension intervals of 15, 30, 45 and 60 mmHg using a solid-state manometry catheter in the colon.
Results: To determine the input sample that best recapitulates the human SI microbiome, we compared the mouse and human SI microbiome following colonization of GF mice with human SI contents or stool (n=3 donors, 3-4 mice/donor). β-diversity-based principal coordinate analysis showed that the SI microbiome of mice, colonized with human SI aspirate, more closely resembled the human input sample (80% of human SI species were present in mouse SI) than the SI microbiome of mice, colonized with human stool (40% of species were retrieved) (Fig. 1). Hence, we colonized GF mice (4-12 mice/donor, 50% males) with SI contents from HC (n=3) or patients with abdominal pain (n=2) to study the effect of SI microbiome on GI physiology. Post-colonization, mice with SI contents from patients had significantly higher VMR to CRD when compared to mice colonized with SI aspirates from HC (Fig. 2). We sequenced human and mouse SI contents from 1 abdominal pain patient and 2 HCs and found a Shigella spp. in the human and mouse SI content from the patient. The relative abundance of Shigella spp. in the mouse SI positively correlated with the VMR to CRD (ρ=0.86, p<0.001).
Conclusion: Human SI contents are better than stool for replicating the human SI microbiome in mice. The presence of Shigella spp. in the SI may underlie visceral hypersensitivity in patients with abdominal pain and represents an important therapeutic target.
<b>Figure 1.</b> Beta diversity-based principal coordinate analysis of SI contents of mice gavaged with human SI aspirates (purple) and human stool (yellow) and the original human input sample (human SI, green and human stool, grey).

Figure 1. Beta diversity-based principal coordinate analysis of SI contents of mice gavaged with human SI aspirates (purple) and human stool (yellow) and the original human input sample (human SI, green and human stool, grey).

<b>Figure 2.</b> SI dysbiosis induces visceral hypersensitivity. The visceromotor response of mice, gavaged with SI aspirates from patients with abdominal pain, was increased at distension pressures of 30, 45 and 60 mmHg when compared to mice, gavaged with SI aspirates from healthy controls. Repeated measurements Two-Way ANOVA with Bonferroni post-hoc correction to account for multiple mice colonized with the same donor sample: *p<0.05, **p<0.01.

Figure 2. SI dysbiosis induces visceral hypersensitivity. The visceromotor response of mice, gavaged with SI aspirates from patients with abdominal pain, was increased at distension pressures of 30, 45 and 60 mmHg when compared to mice, gavaged with SI aspirates from healthy controls. Repeated measurements Two-Way ANOVA with Bonferroni post-hoc correction to account for multiple mice colonized with the same donor sample: *p<0.05, **p<0.01.

Background: We recently showed that splanchnic nerve plays a key role in normal physiology of energy regulation and post-gastric bypass (RYGB), where its activity is significantly increased to induce “browning” of mesenteric fat. Administration of an endocannabinoid receptor-1 (CB1) inverse agonist (Rimonabant) increased splanchnic nerve activity and replicated an energy balance phenotype in mice that similar to that induced by RYGB. We also showed that splanchnic denervation significantly reduces the response to Rimonabant. Methods: We explored : 1) where these peripheral CB1 are located in the gut and how do they mediate their energy regulatory effects using surgical mouse models. 2) whether gut microbiome changes post-gastric bypass mediate the energy effect of the surgery through the CB1-expressing cells. Results: We found that intestinal CB1 co-localizes mainly with CGRP-expressing cells (sensory neurons) and not epithelial, enteroendocrine or immune cells (Figure 1). We then developed and confirmed a model of afferent selective denervation (aSpDNV) using topical capsaicin over celiac ganglia and its branches. Interestingly, aSpDNV mice express a phase of increase food intake but no change in body weight. Furthermore, fecal microbial transfer from RYGB and Sham -operated mice into naïf recipients induces a significant increase in afferent and efferent splanchnic nerve activity of RYGB-stool recipients compared to their controls (Figure 2). Finally, intestinal CB1 expression was significantly lower in RYGB-stool recipients compared to their controls. Conclusion: Gut microbiome can communicate energy signals directly to the brain through CB1-expressing sensory neurons.
BACKGROUND: Modern techniques allow specific target of glial subtypes to examine their roles in visceral hypersensitivity and pain. Satellite glial cells (SGCs) intimately interact with sensory neurons in dorsal root ganglia (DRG), however, their specific roles in regulating DRG neuron activity in intact animals in influencing colonic sensitivity and pain behaviors are not characterized. AIMS: (1) To examine the effects of cell-targeted activation of SGCs on sensory neuron activity/excitability, and (2) to characterize the functional role of SGCs in regulation of colonic mechanosensitivity and pain. METHODS: Using cre-loxP technique to specifically activate SGCs by expressing hM3Dq in proteolipid protein (PLP)- or glial fibrillary acidic protein (GFAP)-expressing cells followed by clozapine N-oxide (CNO, 1-2 mg/kg intraperitoneally (i.p.) or 26 µM intrathecally (i.t.)) treatment. The number of hM3Dq-expressing SGCs is measured by flow cytometry. The activity/excitability of mechanosensory neurons were assessed by electroimaging responding to glass pipette poking or shear stress along with D-GsMtx4, a PIEZO2 inhibitor (10 µM). Colonic mechanosensing was measured by colonometry. Pain behaviors were assessed by hindpaw withdrawal responses to Von-Frey stimulation, hot plate, and gait assay(s). Calcitonin gene-related peptide (CGRP) expression was examined by immunohistochemistry/slot blot. Neurogenic inflammation was assessed by H&E stain. RESULTS: Chemogenetic activation of SGCs (i.p.) induced colonic hypersensitivity and somatic mechanical pain in male but not female mice (n>3; p<0.05), with no change in thermal sensitivity in either sex. hM3Dq expression was strongly present in SGCs of DRG with higher levels in male than female mice (p<0.05), some in hindpaw, and none in the colon or spinal cord of both sexes. Activation of SGCs also increased CGRP levels in DRG neurons (3.5-fold, p<0.05), adjacent to activated SGCs, and in spinal dorsal horn extending to the central commissure in male mice but not female mice, enhanced the activity/excitability of mechanosensory DRG neurons (38/55 (69%) vs 9/23 (39% in control) responding to poking; 260/330 neurons (79%) vs 77/280 (28% in control) responding to shear), and induced neurogenic inflammation in the hindpaw and colon. Results from i.t. CNO-treated Plp;hM3Dq mice and i.p. CNO-treated GFAP;hM3Dq mice recapitulated the behavioral and molecular results in i.p. CNO-treated PLP;hM3Dq mice. CONCLUSION: The augmentation in colonic mechanical sensitivity, somatic mechanical pain, CGRP expression in DRG neurons in male mice but not female mice following SGC activation suggest a sexual dimorphic role of SGCs in regulation of visceral hypersensitivity and pain. Elevation in the activity/excitability of mechanosensory neurons after SGC activation reveal an SGC-mechanosensory neuron crosstalk in pain processing.
Background: Hypoalgesic inflammatory bowel disease (IBD), a condition in which patients with active disease do not perceive and/or report abdominal pain, is associated with serious complications and the lack of reliable, cost-effective methods to identify “at-risk” patients. We previously demonstrated that hypoalgesic IBD is associated with homozygosity for a polymorphism (rs6795970) within the NaV1.8 gene, SCN10A. This is a missense mutation in the coding region associated with dysfunction of NaV1.8. However, it is unclear whether this variant is significantly associated with both hypoalgesic Crohn’s disease (CD) and ulcerative colitis (UC). Methods: We performed a prospective analysis of consecutively recruited patients with an established diagnosis of either CD or UC at a single tertiary care referral center between 9/1/18-8/31/22. Each participant underwent an ileocolonoscopy, completed concomitant surveys (see below) and provided a blood sample for genetic testing. Taqman sequencing was used to genotype individuals based upon the presence or absence of the SCN10A polymorphism, rs6795970. Hypoalgesic patients were identified by having active disease [the presence of a Mayo endoscopy sub-score of 2-3 (UC), or simple endoscopic score of >6 (CD)], and lack of abdominal pain (minimal or no current or chronic abdominal pain in the Short Inflammatory Bowel Disease Questionnaire and Harvey Bradshaw Index/Simple Clinical Colitis Activity Index). Relevant demographic and clinical data were also abstracted. Univariable and multivariable analyses were undertaken to illuminate associations among the study cohorts and factors above. Results: 450 IBD patients (238female, 212male; 295CD, 155UC) were included. 91 patients (20.2%; 53CD, 38UC) had “hypoalgesic IBD” while 359 patients (79.8%; 242 CD, 117 UC) were non-hypoalgesic. Hypoalgesic IBD patients were more likely to be male (63.7% vs. 42.9%, p<0.001), less likely to exhibit anxious or depressed traits (20.2 vs. 63.8%, p<0.01), and less likely to use opioids (14.1 vs. 28.2%, p<0.05) when compared to their counterparts. Hypoalgesic IBD patients (50.5%) were significantly more likely than non-hypoalgesic patients (31.8%) to exhibit homozygosity for rs6795970 (OR:2.20; 1.38-3.51). Hypoalgesic CD (52.8% vs. 33.9%, OR:2.19; 1.20-3.99) and UC (47.4% vs. 27.4%, OR:2.39; 1.12-5.09) patients were also both more likely to exhibit homozygosity for rs6795970 than their symptomatic counterparts. Discussion: Hypoalgesic CD and UC are relatively common, and both are more likely to exhibit homozygosity for the NaV1.8 polymorphism, rs6795970. Our findings provide key insights into the pathophysiology underlying hypoalgesic IBD, and reinforce the importance of NaV1.8 in human visceral pain perception. This work also hints at a potential novel diagnostic and therapeutic target for conditions associated with abdominal pain.

09:00am - 10:30am EDT - May 6, 2023 | Room: S502 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE


Saturday
09:00am - 09:02am EDT - May 6, 2023 | Room: S502 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE


Saturday
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.

Saturday
09:10am - 09:12am EDT - May 6, 2023 | Room: S502 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.

Saturday
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.
Background
Type 2 diabetes (T2D) affects 462 million people worldwide. Non-pharmacological interventions that can improve glycemic control in patients inadequately controlled with glucose-lowering medications (GLMs) have a potential to delay insulin initiation and modify disease progression. Duodenal mucosal regeneration (DMR) induced by thermal ablation has been associated with improved glycemic control in T2D patients.

Pulsed electric field (PEF) is a unique non-thermal modality that can selectively affect cells via electroporation. This first-in-human study evaluates the safety, feasibility and preliminary efficacy of endoscopic application of PEF to elicit DMR in T2D patients inadequately controlled on GLMs and is the first PEF application in gastrointestinal tract.

Method
This is an ongoing multicenter, open-label, treatment-only study. Key eligibility criteria are 18-70 years of age, history of T2D for ≤10 years, HbA1c of 7.5%-11.0%, BMI of 24 – 40 kg/m2, C-peptide ≥ 333 pmol/l, and on 1-4 non-insulin GLMs. The primary endpoint is the incidence of device- or procedure-related serious adverse events (SAEs) at 12 wks. Secondary endpoints include technical success and changes in glycemic control at 24 wks. The procedure is performed endoscopically using the ReCET™ device (Endogenex Inc.). Patients are followed for 48 wks, with endoscopic follow up at 4 wks. The GLMs are maintained stable for ≥12 wks before and ≥24 wks after the procedure.

Results
To date, 30 patients have been enrolled (Table 1). Technical success was 100%, with a mean treated length of 11.0 ± 1.9 cm, and median procedure time of 59 min (IQR 42 – 78). No device/procedure-related SAEs occurred. Forty-five device/procedure-related adverse events (AEs) were reported in 23/30 patients. Most reported AEs were sore throat (17/30) and transient diarrhea (9/30). AEs were mild (80%) or moderate (20%) in severity. At 4 wks, the treated areas showed complete healing, mostly unidentifiable endoscopically, with no signs of stricture, ulceration, or other significant findings.

The first 12 patients were treated with single energy application (single Tx). The subsequent 18 patients received double energy application (double Tx) and 14 have reached 24 wks. Clinically significant improvements in glycemic control were observed in these 14 patients. At 24 wks, mean HbA1c was 7.5% ± 1.1% vs. 8.4% ± 1.0% at baseline (p<0.01), FPG 7.5 ± 1.7 mmol/l vs. 9.8 ± 2.2 mmol/l (P<0.01), and HOMA-IR 4.5 ± 3.6 vs. 7.4 ± 3.3 (p<0.01). Weight loss was 5.1% ± 4.1% (p<0.01) at 24 wks. An energy dose-response relationship was observed between the single Tx and double Tx dose levels (P < 0.05) (Figure 1).

Conclusions
This first GI application of PEF in human demonstrated that the technology is feasible, safe, well tolerated by patients, and is associated with clinically meaningful improvement in glycemic control.

Saturday
09:20am - 09:22am EDT - May 6, 2023 | Room: S502 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.
Background
Type 2 diabetes (T2D) affects 462 million people worldwide. Non-pharmacological interventions that can improve glycemic control in patients inadequately controlled with glucose-lowering medications (GLMs) have a potential to delay insulin initiation and modify disease progression. Duodenal mucosal regeneration (DMR) induced by thermal ablation has been associated with improved glycemic control in T2D patients.

Pulsed electric field (PEF) is a unique non-thermal modality that can selectively affect cells via electroporation. This first-in-human study evaluates the safety, feasibility and preliminary efficacy of endoscopic application of PEF to elicit DMR in T2D patients inadequately controlled on GLMs and is the first PEF application in gastrointestinal tract.

Method
This is an ongoing multicenter, open-label, treatment-only study. Key eligibility criteria are 18-70 years of age, history of T2D for ≤10 years, HbA1c of 7.5%-11.0%, BMI of 24 – 40 kg/m2, C-peptide ≥ 333 pmol/l, and on 1-4 non-insulin GLMs. The primary endpoint is the incidence of device- or procedure-related serious adverse events (SAEs) at 12 wks. Secondary endpoints include technical success and changes in glycemic control at 24 wks. The procedure is performed endoscopically using the ReCET™ device (Endogenex Inc.). Patients are followed for 48 wks, with endoscopic follow up at 4 wks. The GLMs are maintained stable for ≥12 wks before and ≥24 wks after the procedure.

Results
To date, 30 patients have been enrolled (Table 1). Technical success was 100%, with a mean treated length of 11.0 ± 1.9 cm, and median procedure time of 59 min (IQR 42 – 78). No device/procedure-related SAEs occurred. Forty-five device/procedure-related adverse events (AEs) were reported in 23/30 patients. Most reported AEs were sore throat (17/30) and transient diarrhea (9/30). AEs were mild (80%) or moderate (20%) in severity. At 4 wks, the treated areas showed complete healing, mostly unidentifiable endoscopically, with no signs of stricture, ulceration, or other significant findings.

The first 12 patients were treated with single energy application (single Tx). The subsequent 18 patients received double energy application (double Tx) and 14 have reached 24 wks. Clinically significant improvements in glycemic control were observed in these 14 patients. At 24 wks, mean HbA1c was 7.5% ± 1.1% vs. 8.4% ± 1.0% at baseline (p<0.01), FPG 7.5 ± 1.7 mmol/l vs. 9.8 ± 2.2 mmol/l (P<0.01), and HOMA-IR 4.5 ± 3.6 vs. 7.4 ± 3.3 (p<0.01). Weight loss was 5.1% ± 4.1% (p<0.01) at 24 wks. An energy dose-response relationship was observed between the single Tx and double Tx dose levels (P < 0.05) (Figure 1).

Conclusions
This first GI application of PEF in human demonstrated that the technology is feasible, safe, well tolerated by patients, and is associated with clinically meaningful improvement in glycemic control.

Saturday
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.
Background
Type 2 diabetes (T2D) affects 462 million people worldwide. Non-pharmacological interventions that can improve glycemic control in patients inadequately controlled with glucose-lowering medications (GLMs) have a potential to delay insulin initiation and modify disease progression. Duodenal mucosal regeneration (DMR) induced by thermal ablation has been associated with improved glycemic control in T2D patients.

Pulsed electric field (PEF) is a unique non-thermal modality that can selectively affect cells via electroporation. This first-in-human study evaluates the safety, feasibility and preliminary efficacy of endoscopic application of PEF to elicit DMR in T2D patients inadequately controlled on GLMs and is the first PEF application in gastrointestinal tract.

Method
This is an ongoing multicenter, open-label, treatment-only study. Key eligibility criteria are 18-70 years of age, history of T2D for ≤10 years, HbA1c of 7.5%-11.0%, BMI of 24 – 40 kg/m2, C-peptide ≥ 333 pmol/l, and on 1-4 non-insulin GLMs. The primary endpoint is the incidence of device- or procedure-related serious adverse events (SAEs) at 12 wks. Secondary endpoints include technical success and changes in glycemic control at 24 wks. The procedure is performed endoscopically using the ReCET™ device (Endogenex Inc.). Patients are followed for 48 wks, with endoscopic follow up at 4 wks. The GLMs are maintained stable for ≥12 wks before and ≥24 wks after the procedure.

Results
To date, 30 patients have been enrolled (Table 1). Technical success was 100%, with a mean treated length of 11.0 ± 1.9 cm, and median procedure time of 59 min (IQR 42 – 78). No device/procedure-related SAEs occurred. Forty-five device/procedure-related adverse events (AEs) were reported in 23/30 patients. Most reported AEs were sore throat (17/30) and transient diarrhea (9/30). AEs were mild (80%) or moderate (20%) in severity. At 4 wks, the treated areas showed complete healing, mostly unidentifiable endoscopically, with no signs of stricture, ulceration, or other significant findings.

The first 12 patients were treated with single energy application (single Tx). The subsequent 18 patients received double energy application (double Tx) and 14 have reached 24 wks. Clinically significant improvements in glycemic control were observed in these 14 patients. At 24 wks, mean HbA1c was 7.5% ± 1.1% vs. 8.4% ± 1.0% at baseline (p<0.01), FPG 7.5 ± 1.7 mmol/l vs. 9.8 ± 2.2 mmol/l (P<0.01), and HOMA-IR 4.5 ± 3.6 vs. 7.4 ± 3.3 (p<0.01). Weight loss was 5.1% ± 4.1% (p<0.01) at 24 wks. An energy dose-response relationship was observed between the single Tx and double Tx dose levels (P < 0.05) (Figure 1).

Conclusions
This first GI application of PEF in human demonstrated that the technology is feasible, safe, well tolerated by patients, and is associated with clinically meaningful improvement in glycemic control.
Background: Currently, there are several endoscopic procedures for the treatment of weight regain following Roux-en-Y gastric bypass (RYGB). These include argon plasma coagulation (APC), transoral outlet reduction via suturing (S-TORe) or plication (P-TORe). These procedures focus on reducing the size of the gastrojejunal anastomosis (GJA) and/or pouch. While their safety and efficacy have been established, there is no personalized approach to assist with procedure selection.

Aim: 1) To assess the efficacy of different endoscopic gastric bypass revision (EGBR) procedures 2) To construct an anatomy-based algorithm for the treatment of weight regain to optimize weight loss.

Methods: This is a single-center retrospective study of patients who underwent APC, S-TORe or P-TORe for the treatment of weight regain following RYGB. Patients who underwent EGBR using older suturing or plication platforms were excluded. Sensitivity analyses were performed to compare percent total weight loss (%TWL) at 12 months of different EGBR procedures at different GJA sizes. For pouch ≤ 5 cm, APC and S-TORe were compared as P-TORe is not typically performed given the length of the plication device. For pouch > 5 cm, S-TORe and P-TORe were compared as APC is not typically performed to reduce pouch volume. ANOVA was used for three group comparison and Student’s t-test for sensitivity analyses.

Results: 742 RYGB patients underwent 900 EGBR procedures. Of these, 191 (21%), 591 (66%) and 118 (13%) were APC, S-TORe and P-TORe, respectively. Baseline characteristics are shown in Table 1. At 12 months, patients in the APC, S-TORe and P-TORe experienced 8.1 ± 7.1 %TWL, 9.5 ± 8.7% TWL and 10.0 ± 8.5% TWL, respectively (p =0.25), with 70%, 72% and 63% experiencing at least 5% TWL (p = 0.50). There were no SAEs. Pouch ≤ 5 cm (APC vs S-TORe): On sensitivity analyses, with GJA < 18 mm, there was no difference in %TWL between APC and S-TORe (6.7 ± 7.7 %TWL vs 10.7 ± 11.1 %TWL, p=0.31). With GJA ≥ 18 mm, S-TORe yielded greater weight loss than APC (9.2 ± 8.2% TWL vs 5.3 ± 5.5% TWL, p=0.05). Pouch > 5 cm (S-TORe vs P-TORe): On sensitivity analyses, with GJA ≤ 25 mm, P-TORe yielded greater weight loss compared to S-TORe (13.2 ± 7.5%TWL vs 9.5 ± 9.1% TWL, p=0.04). With GJA > 25 mm, S-TORe yielded greater weight loss compared to P-TORe (17.1 ± 17.5% TWL vs -0.2 ± 7.5% TWL, p=0.03). Using results of the sensitivity analyses at different GJA size, an algorithm for the management of weight regain is constructed (Figure 1).

Conclusion: Endoscopic revision of RYGB in the treatment of weight regain can be individualized based on patient anatomy. For pouch ≤ 5 cm, S-TORe should be considered when GJA ≥ 18 mm, while either S-TORe or APC can be offered when GJA < 18 mm. For pouch > 5 cm, S-TORe should be considered when GJA > 25 mm, with P-TORe being offered when GJA ≤ 25 mm.
<b>Table 1</b>. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

Table 1. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

<b>Figure 1</b>. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Figure 1. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.


Saturday
09:30am - 09:32am EDT - May 6, 2023 | Room: S502 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.
Background
Type 2 diabetes (T2D) affects 462 million people worldwide. Non-pharmacological interventions that can improve glycemic control in patients inadequately controlled with glucose-lowering medications (GLMs) have a potential to delay insulin initiation and modify disease progression. Duodenal mucosal regeneration (DMR) induced by thermal ablation has been associated with improved glycemic control in T2D patients.

Pulsed electric field (PEF) is a unique non-thermal modality that can selectively affect cells via electroporation. This first-in-human study evaluates the safety, feasibility and preliminary efficacy of endoscopic application of PEF to elicit DMR in T2D patients inadequately controlled on GLMs and is the first PEF application in gastrointestinal tract.

Method
This is an ongoing multicenter, open-label, treatment-only study. Key eligibility criteria are 18-70 years of age, history of T2D for ≤10 years, HbA1c of 7.5%-11.0%, BMI of 24 – 40 kg/m2, C-peptide ≥ 333 pmol/l, and on 1-4 non-insulin GLMs. The primary endpoint is the incidence of device- or procedure-related serious adverse events (SAEs) at 12 wks. Secondary endpoints include technical success and changes in glycemic control at 24 wks. The procedure is performed endoscopically using the ReCET™ device (Endogenex Inc.). Patients are followed for 48 wks, with endoscopic follow up at 4 wks. The GLMs are maintained stable for ≥12 wks before and ≥24 wks after the procedure.

Results
To date, 30 patients have been enrolled (Table 1). Technical success was 100%, with a mean treated length of 11.0 ± 1.9 cm, and median procedure time of 59 min (IQR 42 – 78). No device/procedure-related SAEs occurred. Forty-five device/procedure-related adverse events (AEs) were reported in 23/30 patients. Most reported AEs were sore throat (17/30) and transient diarrhea (9/30). AEs were mild (80%) or moderate (20%) in severity. At 4 wks, the treated areas showed complete healing, mostly unidentifiable endoscopically, with no signs of stricture, ulceration, or other significant findings.

The first 12 patients were treated with single energy application (single Tx). The subsequent 18 patients received double energy application (double Tx) and 14 have reached 24 wks. Clinically significant improvements in glycemic control were observed in these 14 patients. At 24 wks, mean HbA1c was 7.5% ± 1.1% vs. 8.4% ± 1.0% at baseline (p<0.01), FPG 7.5 ± 1.7 mmol/l vs. 9.8 ± 2.2 mmol/l (P<0.01), and HOMA-IR 4.5 ± 3.6 vs. 7.4 ± 3.3 (p<0.01). Weight loss was 5.1% ± 4.1% (p<0.01) at 24 wks. An energy dose-response relationship was observed between the single Tx and double Tx dose levels (P < 0.05) (Figure 1).

Conclusions
This first GI application of PEF in human demonstrated that the technology is feasible, safe, well tolerated by patients, and is associated with clinically meaningful improvement in glycemic control.
Background: Currently, there are several endoscopic procedures for the treatment of weight regain following Roux-en-Y gastric bypass (RYGB). These include argon plasma coagulation (APC), transoral outlet reduction via suturing (S-TORe) or plication (P-TORe). These procedures focus on reducing the size of the gastrojejunal anastomosis (GJA) and/or pouch. While their safety and efficacy have been established, there is no personalized approach to assist with procedure selection.

Aim: 1) To assess the efficacy of different endoscopic gastric bypass revision (EGBR) procedures 2) To construct an anatomy-based algorithm for the treatment of weight regain to optimize weight loss.

Methods: This is a single-center retrospective study of patients who underwent APC, S-TORe or P-TORe for the treatment of weight regain following RYGB. Patients who underwent EGBR using older suturing or plication platforms were excluded. Sensitivity analyses were performed to compare percent total weight loss (%TWL) at 12 months of different EGBR procedures at different GJA sizes. For pouch ≤ 5 cm, APC and S-TORe were compared as P-TORe is not typically performed given the length of the plication device. For pouch > 5 cm, S-TORe and P-TORe were compared as APC is not typically performed to reduce pouch volume. ANOVA was used for three group comparison and Student’s t-test for sensitivity analyses.

Results: 742 RYGB patients underwent 900 EGBR procedures. Of these, 191 (21%), 591 (66%) and 118 (13%) were APC, S-TORe and P-TORe, respectively. Baseline characteristics are shown in Table 1. At 12 months, patients in the APC, S-TORe and P-TORe experienced 8.1 ± 7.1 %TWL, 9.5 ± 8.7% TWL and 10.0 ± 8.5% TWL, respectively (p =0.25), with 70%, 72% and 63% experiencing at least 5% TWL (p = 0.50). There were no SAEs. Pouch ≤ 5 cm (APC vs S-TORe): On sensitivity analyses, with GJA < 18 mm, there was no difference in %TWL between APC and S-TORe (6.7 ± 7.7 %TWL vs 10.7 ± 11.1 %TWL, p=0.31). With GJA ≥ 18 mm, S-TORe yielded greater weight loss than APC (9.2 ± 8.2% TWL vs 5.3 ± 5.5% TWL, p=0.05). Pouch > 5 cm (S-TORe vs P-TORe): On sensitivity analyses, with GJA ≤ 25 mm, P-TORe yielded greater weight loss compared to S-TORe (13.2 ± 7.5%TWL vs 9.5 ± 9.1% TWL, p=0.04). With GJA > 25 mm, S-TORe yielded greater weight loss compared to P-TORe (17.1 ± 17.5% TWL vs -0.2 ± 7.5% TWL, p=0.03). Using results of the sensitivity analyses at different GJA size, an algorithm for the management of weight regain is constructed (Figure 1).

Conclusion: Endoscopic revision of RYGB in the treatment of weight regain can be individualized based on patient anatomy. For pouch ≤ 5 cm, S-TORe should be considered when GJA ≥ 18 mm, while either S-TORe or APC can be offered when GJA < 18 mm. For pouch > 5 cm, S-TORe should be considered when GJA > 25 mm, with P-TORe being offered when GJA ≤ 25 mm.
<b>Table 1</b>. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

Table 1. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

<b>Figure 1</b>. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Figure 1. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.


Saturday
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.
Background
Type 2 diabetes (T2D) affects 462 million people worldwide. Non-pharmacological interventions that can improve glycemic control in patients inadequately controlled with glucose-lowering medications (GLMs) have a potential to delay insulin initiation and modify disease progression. Duodenal mucosal regeneration (DMR) induced by thermal ablation has been associated with improved glycemic control in T2D patients.

Pulsed electric field (PEF) is a unique non-thermal modality that can selectively affect cells via electroporation. This first-in-human study evaluates the safety, feasibility and preliminary efficacy of endoscopic application of PEF to elicit DMR in T2D patients inadequately controlled on GLMs and is the first PEF application in gastrointestinal tract.

Method
This is an ongoing multicenter, open-label, treatment-only study. Key eligibility criteria are 18-70 years of age, history of T2D for ≤10 years, HbA1c of 7.5%-11.0%, BMI of 24 – 40 kg/m2, C-peptide ≥ 333 pmol/l, and on 1-4 non-insulin GLMs. The primary endpoint is the incidence of device- or procedure-related serious adverse events (SAEs) at 12 wks. Secondary endpoints include technical success and changes in glycemic control at 24 wks. The procedure is performed endoscopically using the ReCET™ device (Endogenex Inc.). Patients are followed for 48 wks, with endoscopic follow up at 4 wks. The GLMs are maintained stable for ≥12 wks before and ≥24 wks after the procedure.

Results
To date, 30 patients have been enrolled (Table 1). Technical success was 100%, with a mean treated length of 11.0 ± 1.9 cm, and median procedure time of 59 min (IQR 42 – 78). No device/procedure-related SAEs occurred. Forty-five device/procedure-related adverse events (AEs) were reported in 23/30 patients. Most reported AEs were sore throat (17/30) and transient diarrhea (9/30). AEs were mild (80%) or moderate (20%) in severity. At 4 wks, the treated areas showed complete healing, mostly unidentifiable endoscopically, with no signs of stricture, ulceration, or other significant findings.

The first 12 patients were treated with single energy application (single Tx). The subsequent 18 patients received double energy application (double Tx) and 14 have reached 24 wks. Clinically significant improvements in glycemic control were observed in these 14 patients. At 24 wks, mean HbA1c was 7.5% ± 1.1% vs. 8.4% ± 1.0% at baseline (p<0.01), FPG 7.5 ± 1.7 mmol/l vs. 9.8 ± 2.2 mmol/l (P<0.01), and HOMA-IR 4.5 ± 3.6 vs. 7.4 ± 3.3 (p<0.01). Weight loss was 5.1% ± 4.1% (p<0.01) at 24 wks. An energy dose-response relationship was observed between the single Tx and double Tx dose levels (P < 0.05) (Figure 1).

Conclusions
This first GI application of PEF in human demonstrated that the technology is feasible, safe, well tolerated by patients, and is associated with clinically meaningful improvement in glycemic control.
Background: Currently, there are several endoscopic procedures for the treatment of weight regain following Roux-en-Y gastric bypass (RYGB). These include argon plasma coagulation (APC), transoral outlet reduction via suturing (S-TORe) or plication (P-TORe). These procedures focus on reducing the size of the gastrojejunal anastomosis (GJA) and/or pouch. While their safety and efficacy have been established, there is no personalized approach to assist with procedure selection.

Aim: 1) To assess the efficacy of different endoscopic gastric bypass revision (EGBR) procedures 2) To construct an anatomy-based algorithm for the treatment of weight regain to optimize weight loss.

Methods: This is a single-center retrospective study of patients who underwent APC, S-TORe or P-TORe for the treatment of weight regain following RYGB. Patients who underwent EGBR using older suturing or plication platforms were excluded. Sensitivity analyses were performed to compare percent total weight loss (%TWL) at 12 months of different EGBR procedures at different GJA sizes. For pouch ≤ 5 cm, APC and S-TORe were compared as P-TORe is not typically performed given the length of the plication device. For pouch > 5 cm, S-TORe and P-TORe were compared as APC is not typically performed to reduce pouch volume. ANOVA was used for three group comparison and Student’s t-test for sensitivity analyses.

Results: 742 RYGB patients underwent 900 EGBR procedures. Of these, 191 (21%), 591 (66%) and 118 (13%) were APC, S-TORe and P-TORe, respectively. Baseline characteristics are shown in Table 1. At 12 months, patients in the APC, S-TORe and P-TORe experienced 8.1 ± 7.1 %TWL, 9.5 ± 8.7% TWL and 10.0 ± 8.5% TWL, respectively (p =0.25), with 70%, 72% and 63% experiencing at least 5% TWL (p = 0.50). There were no SAEs. Pouch ≤ 5 cm (APC vs S-TORe): On sensitivity analyses, with GJA < 18 mm, there was no difference in %TWL between APC and S-TORe (6.7 ± 7.7 %TWL vs 10.7 ± 11.1 %TWL, p=0.31). With GJA ≥ 18 mm, S-TORe yielded greater weight loss than APC (9.2 ± 8.2% TWL vs 5.3 ± 5.5% TWL, p=0.05). Pouch > 5 cm (S-TORe vs P-TORe): On sensitivity analyses, with GJA ≤ 25 mm, P-TORe yielded greater weight loss compared to S-TORe (13.2 ± 7.5%TWL vs 9.5 ± 9.1% TWL, p=0.04). With GJA > 25 mm, S-TORe yielded greater weight loss compared to P-TORe (17.1 ± 17.5% TWL vs -0.2 ± 7.5% TWL, p=0.03). Using results of the sensitivity analyses at different GJA size, an algorithm for the management of weight regain is constructed (Figure 1).

Conclusion: Endoscopic revision of RYGB in the treatment of weight regain can be individualized based on patient anatomy. For pouch ≤ 5 cm, S-TORe should be considered when GJA ≥ 18 mm, while either S-TORe or APC can be offered when GJA < 18 mm. For pouch > 5 cm, S-TORe should be considered when GJA > 25 mm, with P-TORe being offered when GJA ≤ 25 mm.
<b>Table 1</b>. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

Table 1. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

<b>Figure 1</b>. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Figure 1. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Introduction: Super-Obese patients presenting several comorbidities put foward a dilemma due to high perioperative adverse event rates. Although bariatric surgery remains to this moment the Gold standard of treatment while approaching those patients, not only as weight loss tools, but regarding their impact as metabolic procedures, only a small parcel accepts this option. Fear of complications even in then presence of extensive detailment opens a possibility for other solutions. Bariatric endoscopy proposes minimally invasive proceedings that can be an alternative not merely regarding weight loss but to the amelioration of comorbidities. Hence, it can postpone or even bypass surgery.
Objectives:
Methods: A cohort of 76 patients( mean age 43±7) with a BMI above 50 (51-63)was prospecticaly recruited and analysed retrospectively from February 2018 to January 2021. They were engaged to accomplish two consecutive endobariatric approaches. Firstly, a six-month nonadjustable intragastric balloon was placed, and at the time of the explant, an endoscopic sleeve Gastroplasty(Apollo Endosurgery) was executed.Weight loss results; Body mass composition (Inbody 720), elastography (Fibroscan, Echosens), HOMA-IR, Glicated Haemoglobin, Triglyceride levels, 24-Hour Ambulatory Blood Pressure Monitoring (ABPM), Sleep Apnea Disorders (polysommnography) were analysed by the student t test and the Wilcoxon test.
Results: 68 patients (55 females) completed the two consecutive procedures(3 early balloon removals; 2 not eligible for ESG at the time proposed and 3 opted for bariatric surgery )The average total body weight loss at IGB removal/ESG procedure was 19.74%(±4.67).ESG was accomplished with sucess on all, using an average of 5.6 sutures (4-7) with 15-22 bites per suture. One patient required hospitalization due to difficulty in extubation (2-day admission). No serious adverse event was reported. At 12 months, TBWL % was 32.57%.(+-9.79). 58 patients(75%), presented type 2 diabetes, and 88.2% had their medications decreased, with an average decrease in Hb1ac of 1.65%(+-1.22). Steatosis was present in 82% of patients (S2 score predominant;) and fibrosis in 21% of the group (F3 predominant).Improvements in 69.64 and 50 percent respectively(p<0.001) Sleep apnea in 69.11% with a betterment in 82.97%(p<0.001)ABPM melioration in all HBP bearers(p<0.001).
Conclusion: Although 18 Months were necessary to achieve those results, WL and betterment in comorbidities were similar to those reported after a surgical technique. The role of Endobariatrics broadens to other classes of patients rather than the predetermined originally to fill the gap between clinical and surgical approaches, targeting patients with a BMI of 30-40) and provides safe, effective and life-changing modifications.Therefore,could be offered as an alternative to those who can not or don not wish to undergo surgery.

Saturday
09:40am - 09:42am EDT - May 6, 2023 | Room: S502 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.
Background
Type 2 diabetes (T2D) affects 462 million people worldwide. Non-pharmacological interventions that can improve glycemic control in patients inadequately controlled with glucose-lowering medications (GLMs) have a potential to delay insulin initiation and modify disease progression. Duodenal mucosal regeneration (DMR) induced by thermal ablation has been associated with improved glycemic control in T2D patients.

Pulsed electric field (PEF) is a unique non-thermal modality that can selectively affect cells via electroporation. This first-in-human study evaluates the safety, feasibility and preliminary efficacy of endoscopic application of PEF to elicit DMR in T2D patients inadequately controlled on GLMs and is the first PEF application in gastrointestinal tract.

Method
This is an ongoing multicenter, open-label, treatment-only study. Key eligibility criteria are 18-70 years of age, history of T2D for ≤10 years, HbA1c of 7.5%-11.0%, BMI of 24 – 40 kg/m2, C-peptide ≥ 333 pmol/l, and on 1-4 non-insulin GLMs. The primary endpoint is the incidence of device- or procedure-related serious adverse events (SAEs) at 12 wks. Secondary endpoints include technical success and changes in glycemic control at 24 wks. The procedure is performed endoscopically using the ReCET™ device (Endogenex Inc.). Patients are followed for 48 wks, with endoscopic follow up at 4 wks. The GLMs are maintained stable for ≥12 wks before and ≥24 wks after the procedure.

Results
To date, 30 patients have been enrolled (Table 1). Technical success was 100%, with a mean treated length of 11.0 ± 1.9 cm, and median procedure time of 59 min (IQR 42 – 78). No device/procedure-related SAEs occurred. Forty-five device/procedure-related adverse events (AEs) were reported in 23/30 patients. Most reported AEs were sore throat (17/30) and transient diarrhea (9/30). AEs were mild (80%) or moderate (20%) in severity. At 4 wks, the treated areas showed complete healing, mostly unidentifiable endoscopically, with no signs of stricture, ulceration, or other significant findings.

The first 12 patients were treated with single energy application (single Tx). The subsequent 18 patients received double energy application (double Tx) and 14 have reached 24 wks. Clinically significant improvements in glycemic control were observed in these 14 patients. At 24 wks, mean HbA1c was 7.5% ± 1.1% vs. 8.4% ± 1.0% at baseline (p<0.01), FPG 7.5 ± 1.7 mmol/l vs. 9.8 ± 2.2 mmol/l (P<0.01), and HOMA-IR 4.5 ± 3.6 vs. 7.4 ± 3.3 (p<0.01). Weight loss was 5.1% ± 4.1% (p<0.01) at 24 wks. An energy dose-response relationship was observed between the single Tx and double Tx dose levels (P < 0.05) (Figure 1).

Conclusions
This first GI application of PEF in human demonstrated that the technology is feasible, safe, well tolerated by patients, and is associated with clinically meaningful improvement in glycemic control.
Background: Currently, there are several endoscopic procedures for the treatment of weight regain following Roux-en-Y gastric bypass (RYGB). These include argon plasma coagulation (APC), transoral outlet reduction via suturing (S-TORe) or plication (P-TORe). These procedures focus on reducing the size of the gastrojejunal anastomosis (GJA) and/or pouch. While their safety and efficacy have been established, there is no personalized approach to assist with procedure selection.

Aim: 1) To assess the efficacy of different endoscopic gastric bypass revision (EGBR) procedures 2) To construct an anatomy-based algorithm for the treatment of weight regain to optimize weight loss.

Methods: This is a single-center retrospective study of patients who underwent APC, S-TORe or P-TORe for the treatment of weight regain following RYGB. Patients who underwent EGBR using older suturing or plication platforms were excluded. Sensitivity analyses were performed to compare percent total weight loss (%TWL) at 12 months of different EGBR procedures at different GJA sizes. For pouch ≤ 5 cm, APC and S-TORe were compared as P-TORe is not typically performed given the length of the plication device. For pouch > 5 cm, S-TORe and P-TORe were compared as APC is not typically performed to reduce pouch volume. ANOVA was used for three group comparison and Student’s t-test for sensitivity analyses.

Results: 742 RYGB patients underwent 900 EGBR procedures. Of these, 191 (21%), 591 (66%) and 118 (13%) were APC, S-TORe and P-TORe, respectively. Baseline characteristics are shown in Table 1. At 12 months, patients in the APC, S-TORe and P-TORe experienced 8.1 ± 7.1 %TWL, 9.5 ± 8.7% TWL and 10.0 ± 8.5% TWL, respectively (p =0.25), with 70%, 72% and 63% experiencing at least 5% TWL (p = 0.50). There were no SAEs. Pouch ≤ 5 cm (APC vs S-TORe): On sensitivity analyses, with GJA < 18 mm, there was no difference in %TWL between APC and S-TORe (6.7 ± 7.7 %TWL vs 10.7 ± 11.1 %TWL, p=0.31). With GJA ≥ 18 mm, S-TORe yielded greater weight loss than APC (9.2 ± 8.2% TWL vs 5.3 ± 5.5% TWL, p=0.05). Pouch > 5 cm (S-TORe vs P-TORe): On sensitivity analyses, with GJA ≤ 25 mm, P-TORe yielded greater weight loss compared to S-TORe (13.2 ± 7.5%TWL vs 9.5 ± 9.1% TWL, p=0.04). With GJA > 25 mm, S-TORe yielded greater weight loss compared to P-TORe (17.1 ± 17.5% TWL vs -0.2 ± 7.5% TWL, p=0.03). Using results of the sensitivity analyses at different GJA size, an algorithm for the management of weight regain is constructed (Figure 1).

Conclusion: Endoscopic revision of RYGB in the treatment of weight regain can be individualized based on patient anatomy. For pouch ≤ 5 cm, S-TORe should be considered when GJA ≥ 18 mm, while either S-TORe or APC can be offered when GJA < 18 mm. For pouch > 5 cm, S-TORe should be considered when GJA > 25 mm, with P-TORe being offered when GJA ≤ 25 mm.
<b>Table 1</b>. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

Table 1. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

<b>Figure 1</b>. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Figure 1. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Introduction: Super-Obese patients presenting several comorbidities put foward a dilemma due to high perioperative adverse event rates. Although bariatric surgery remains to this moment the Gold standard of treatment while approaching those patients, not only as weight loss tools, but regarding their impact as metabolic procedures, only a small parcel accepts this option. Fear of complications even in then presence of extensive detailment opens a possibility for other solutions. Bariatric endoscopy proposes minimally invasive proceedings that can be an alternative not merely regarding weight loss but to the amelioration of comorbidities. Hence, it can postpone or even bypass surgery.
Objectives:
Methods: A cohort of 76 patients( mean age 43±7) with a BMI above 50 (51-63)was prospecticaly recruited and analysed retrospectively from February 2018 to January 2021. They were engaged to accomplish two consecutive endobariatric approaches. Firstly, a six-month nonadjustable intragastric balloon was placed, and at the time of the explant, an endoscopic sleeve Gastroplasty(Apollo Endosurgery) was executed.Weight loss results; Body mass composition (Inbody 720), elastography (Fibroscan, Echosens), HOMA-IR, Glicated Haemoglobin, Triglyceride levels, 24-Hour Ambulatory Blood Pressure Monitoring (ABPM), Sleep Apnea Disorders (polysommnography) were analysed by the student t test and the Wilcoxon test.
Results: 68 patients (55 females) completed the two consecutive procedures(3 early balloon removals; 2 not eligible for ESG at the time proposed and 3 opted for bariatric surgery )The average total body weight loss at IGB removal/ESG procedure was 19.74%(±4.67).ESG was accomplished with sucess on all, using an average of 5.6 sutures (4-7) with 15-22 bites per suture. One patient required hospitalization due to difficulty in extubation (2-day admission). No serious adverse event was reported. At 12 months, TBWL % was 32.57%.(+-9.79). 58 patients(75%), presented type 2 diabetes, and 88.2% had their medications decreased, with an average decrease in Hb1ac of 1.65%(+-1.22). Steatosis was present in 82% of patients (S2 score predominant;) and fibrosis in 21% of the group (F3 predominant).Improvements in 69.64 and 50 percent respectively(p<0.001) Sleep apnea in 69.11% with a betterment in 82.97%(p<0.001)ABPM melioration in all HBP bearers(p<0.001).
Conclusion: Although 18 Months were necessary to achieve those results, WL and betterment in comorbidities were similar to those reported after a surgical technique. The role of Endobariatrics broadens to other classes of patients rather than the predetermined originally to fill the gap between clinical and surgical approaches, targeting patients with a BMI of 30-40) and provides safe, effective and life-changing modifications.Therefore,could be offered as an alternative to those who can not or don not wish to undergo surgery.

Saturday
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.
Background
Type 2 diabetes (T2D) affects 462 million people worldwide. Non-pharmacological interventions that can improve glycemic control in patients inadequately controlled with glucose-lowering medications (GLMs) have a potential to delay insulin initiation and modify disease progression. Duodenal mucosal regeneration (DMR) induced by thermal ablation has been associated with improved glycemic control in T2D patients.

Pulsed electric field (PEF) is a unique non-thermal modality that can selectively affect cells via electroporation. This first-in-human study evaluates the safety, feasibility and preliminary efficacy of endoscopic application of PEF to elicit DMR in T2D patients inadequately controlled on GLMs and is the first PEF application in gastrointestinal tract.

Method
This is an ongoing multicenter, open-label, treatment-only study. Key eligibility criteria are 18-70 years of age, history of T2D for ≤10 years, HbA1c of 7.5%-11.0%, BMI of 24 – 40 kg/m2, C-peptide ≥ 333 pmol/l, and on 1-4 non-insulin GLMs. The primary endpoint is the incidence of device- or procedure-related serious adverse events (SAEs) at 12 wks. Secondary endpoints include technical success and changes in glycemic control at 24 wks. The procedure is performed endoscopically using the ReCET™ device (Endogenex Inc.). Patients are followed for 48 wks, with endoscopic follow up at 4 wks. The GLMs are maintained stable for ≥12 wks before and ≥24 wks after the procedure.

Results
To date, 30 patients have been enrolled (Table 1). Technical success was 100%, with a mean treated length of 11.0 ± 1.9 cm, and median procedure time of 59 min (IQR 42 – 78). No device/procedure-related SAEs occurred. Forty-five device/procedure-related adverse events (AEs) were reported in 23/30 patients. Most reported AEs were sore throat (17/30) and transient diarrhea (9/30). AEs were mild (80%) or moderate (20%) in severity. At 4 wks, the treated areas showed complete healing, mostly unidentifiable endoscopically, with no signs of stricture, ulceration, or other significant findings.

The first 12 patients were treated with single energy application (single Tx). The subsequent 18 patients received double energy application (double Tx) and 14 have reached 24 wks. Clinically significant improvements in glycemic control were observed in these 14 patients. At 24 wks, mean HbA1c was 7.5% ± 1.1% vs. 8.4% ± 1.0% at baseline (p<0.01), FPG 7.5 ± 1.7 mmol/l vs. 9.8 ± 2.2 mmol/l (P<0.01), and HOMA-IR 4.5 ± 3.6 vs. 7.4 ± 3.3 (p<0.01). Weight loss was 5.1% ± 4.1% (p<0.01) at 24 wks. An energy dose-response relationship was observed between the single Tx and double Tx dose levels (P < 0.05) (Figure 1).

Conclusions
This first GI application of PEF in human demonstrated that the technology is feasible, safe, well tolerated by patients, and is associated with clinically meaningful improvement in glycemic control.
Background: Currently, there are several endoscopic procedures for the treatment of weight regain following Roux-en-Y gastric bypass (RYGB). These include argon plasma coagulation (APC), transoral outlet reduction via suturing (S-TORe) or plication (P-TORe). These procedures focus on reducing the size of the gastrojejunal anastomosis (GJA) and/or pouch. While their safety and efficacy have been established, there is no personalized approach to assist with procedure selection.

Aim: 1) To assess the efficacy of different endoscopic gastric bypass revision (EGBR) procedures 2) To construct an anatomy-based algorithm for the treatment of weight regain to optimize weight loss.

Methods: This is a single-center retrospective study of patients who underwent APC, S-TORe or P-TORe for the treatment of weight regain following RYGB. Patients who underwent EGBR using older suturing or plication platforms were excluded. Sensitivity analyses were performed to compare percent total weight loss (%TWL) at 12 months of different EGBR procedures at different GJA sizes. For pouch ≤ 5 cm, APC and S-TORe were compared as P-TORe is not typically performed given the length of the plication device. For pouch > 5 cm, S-TORe and P-TORe were compared as APC is not typically performed to reduce pouch volume. ANOVA was used for three group comparison and Student’s t-test for sensitivity analyses.

Results: 742 RYGB patients underwent 900 EGBR procedures. Of these, 191 (21%), 591 (66%) and 118 (13%) were APC, S-TORe and P-TORe, respectively. Baseline characteristics are shown in Table 1. At 12 months, patients in the APC, S-TORe and P-TORe experienced 8.1 ± 7.1 %TWL, 9.5 ± 8.7% TWL and 10.0 ± 8.5% TWL, respectively (p =0.25), with 70%, 72% and 63% experiencing at least 5% TWL (p = 0.50). There were no SAEs. Pouch ≤ 5 cm (APC vs S-TORe): On sensitivity analyses, with GJA < 18 mm, there was no difference in %TWL between APC and S-TORe (6.7 ± 7.7 %TWL vs 10.7 ± 11.1 %TWL, p=0.31). With GJA ≥ 18 mm, S-TORe yielded greater weight loss than APC (9.2 ± 8.2% TWL vs 5.3 ± 5.5% TWL, p=0.05). Pouch > 5 cm (S-TORe vs P-TORe): On sensitivity analyses, with GJA ≤ 25 mm, P-TORe yielded greater weight loss compared to S-TORe (13.2 ± 7.5%TWL vs 9.5 ± 9.1% TWL, p=0.04). With GJA > 25 mm, S-TORe yielded greater weight loss compared to P-TORe (17.1 ± 17.5% TWL vs -0.2 ± 7.5% TWL, p=0.03). Using results of the sensitivity analyses at different GJA size, an algorithm for the management of weight regain is constructed (Figure 1).

Conclusion: Endoscopic revision of RYGB in the treatment of weight regain can be individualized based on patient anatomy. For pouch ≤ 5 cm, S-TORe should be considered when GJA ≥ 18 mm, while either S-TORe or APC can be offered when GJA < 18 mm. For pouch > 5 cm, S-TORe should be considered when GJA > 25 mm, with P-TORe being offered when GJA ≤ 25 mm.
<b>Table 1</b>. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

Table 1. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

<b>Figure 1</b>. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Figure 1. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Introduction: Super-Obese patients presenting several comorbidities put foward a dilemma due to high perioperative adverse event rates. Although bariatric surgery remains to this moment the Gold standard of treatment while approaching those patients, not only as weight loss tools, but regarding their impact as metabolic procedures, only a small parcel accepts this option. Fear of complications even in then presence of extensive detailment opens a possibility for other solutions. Bariatric endoscopy proposes minimally invasive proceedings that can be an alternative not merely regarding weight loss but to the amelioration of comorbidities. Hence, it can postpone or even bypass surgery.
Objectives:
Methods: A cohort of 76 patients( mean age 43±7) with a BMI above 50 (51-63)was prospecticaly recruited and analysed retrospectively from February 2018 to January 2021. They were engaged to accomplish two consecutive endobariatric approaches. Firstly, a six-month nonadjustable intragastric balloon was placed, and at the time of the explant, an endoscopic sleeve Gastroplasty(Apollo Endosurgery) was executed.Weight loss results; Body mass composition (Inbody 720), elastography (Fibroscan, Echosens), HOMA-IR, Glicated Haemoglobin, Triglyceride levels, 24-Hour Ambulatory Blood Pressure Monitoring (ABPM), Sleep Apnea Disorders (polysommnography) were analysed by the student t test and the Wilcoxon test.
Results: 68 patients (55 females) completed the two consecutive procedures(3 early balloon removals; 2 not eligible for ESG at the time proposed and 3 opted for bariatric surgery )The average total body weight loss at IGB removal/ESG procedure was 19.74%(±4.67).ESG was accomplished with sucess on all, using an average of 5.6 sutures (4-7) with 15-22 bites per suture. One patient required hospitalization due to difficulty in extubation (2-day admission). No serious adverse event was reported. At 12 months, TBWL % was 32.57%.(+-9.79). 58 patients(75%), presented type 2 diabetes, and 88.2% had their medications decreased, with an average decrease in Hb1ac of 1.65%(+-1.22). Steatosis was present in 82% of patients (S2 score predominant;) and fibrosis in 21% of the group (F3 predominant).Improvements in 69.64 and 50 percent respectively(p<0.001) Sleep apnea in 69.11% with a betterment in 82.97%(p<0.001)ABPM melioration in all HBP bearers(p<0.001).
Conclusion: Although 18 Months were necessary to achieve those results, WL and betterment in comorbidities were similar to those reported after a surgical technique. The role of Endobariatrics broadens to other classes of patients rather than the predetermined originally to fill the gap between clinical and surgical approaches, targeting patients with a BMI of 30-40) and provides safe, effective and life-changing modifications.Therefore,could be offered as an alternative to those who can not or don not wish to undergo surgery.
Background and Aim: Current endoscopic bariatric therapies fail to achieve the same degree of weight loss and improvement in metabolic profile similar to laparoscopic sleeve gastrectomy (LSG) because they merely mimic its restrictive/anatomic aspects. Four essential requirements should be met to achieve the same anatomical and physiological benefits of surgery: (a) reducing gastric volume, (b) decreasing gastric compliance, (c) increasing gastric emptying, and (d) eradicating the hormonally active gastric mucosa. We aim to replicate the efficacy of LSG through a safe, simple, and effective endoscopic approach. We hypothesized that an endoscopic submucosal injection of a sclerosant agent can induce gastric remodeling that will mimic the effects of LSG.
Methods: To better simulate human physiology, we designed a 3D organ-on-a-chip (OoC) intestinal culture model to control cell
microenvironments and maintain tissue-specific functions. The OoC was constructed using co-culture of human intestinal epithelial cells (InEpC), human intestinal myofibroblasts (InMyoFib), and colon carcinoma cell line (Caco-2). The OoC was then treated with bleomycin (1, 1.5, and 2 ug/ml); minocycline (5,10, and 20 mg/ml); recombinant TGF-beta1 (10, 20, and 40 ng/ml), and negative control (Sodium Tetradecyl Sulfate;1000 uM). After initial cell viability testing, we performed immunostaining to detect the expression of fibrosis biomarkers: alpha-smooth muscle actin (alpha-SMA), and collagen-1 (Col-1). The examination was performed using high-resolution confocal microscopy
seven days after incubation.
Results: Bioprinted acellular tubes were constructed and cocultured with the selected cells successfully. The initial viability tests showed that most cells in the OoC culture survived the range of doses of the three candidate agents. However, there was a dose-dependent increase in the cell death ratio (Figure 1). Immunostaining showed that the three candidate agents induced a dose-dependent increase in the fibrotic reaction as evidenced by alpha-SMA actin and Col-1 expression compared to the control. The drug doses that produced the best outcome balance for cell death to the fibrotic reaction were 1.5 ug/ml for bleomycin, 10 mg/ml for minocycline, and 40 ng/ml for TGF-beta1 (Figure 2).
Conclusion: We successfully designed a 3D organ-on-a-chip intestinal culture model and induced an intense fibrotic reaction with bleomycin, minocycline, and recombinant TGF-beta1. This culture model represents a platform for future gastrointestinal research applications. We are currently leveraging our experience on this model to rodent and porcine animal models. The ultimate goal is to develop a single outpatient endoscopic procedure to treat obesity that does not require advanced endoscopic techniques and can be easily disseminated.
Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).


Saturday
09:50am - 09:52am EDT - May 6, 2023 | Room: S502 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.
Background
Type 2 diabetes (T2D) affects 462 million people worldwide. Non-pharmacological interventions that can improve glycemic control in patients inadequately controlled with glucose-lowering medications (GLMs) have a potential to delay insulin initiation and modify disease progression. Duodenal mucosal regeneration (DMR) induced by thermal ablation has been associated with improved glycemic control in T2D patients.

Pulsed electric field (PEF) is a unique non-thermal modality that can selectively affect cells via electroporation. This first-in-human study evaluates the safety, feasibility and preliminary efficacy of endoscopic application of PEF to elicit DMR in T2D patients inadequately controlled on GLMs and is the first PEF application in gastrointestinal tract.

Method
This is an ongoing multicenter, open-label, treatment-only study. Key eligibility criteria are 18-70 years of age, history of T2D for ≤10 years, HbA1c of 7.5%-11.0%, BMI of 24 – 40 kg/m2, C-peptide ≥ 333 pmol/l, and on 1-4 non-insulin GLMs. The primary endpoint is the incidence of device- or procedure-related serious adverse events (SAEs) at 12 wks. Secondary endpoints include technical success and changes in glycemic control at 24 wks. The procedure is performed endoscopically using the ReCET™ device (Endogenex Inc.). Patients are followed for 48 wks, with endoscopic follow up at 4 wks. The GLMs are maintained stable for ≥12 wks before and ≥24 wks after the procedure.

Results
To date, 30 patients have been enrolled (Table 1). Technical success was 100%, with a mean treated length of 11.0 ± 1.9 cm, and median procedure time of 59 min (IQR 42 – 78). No device/procedure-related SAEs occurred. Forty-five device/procedure-related adverse events (AEs) were reported in 23/30 patients. Most reported AEs were sore throat (17/30) and transient diarrhea (9/30). AEs were mild (80%) or moderate (20%) in severity. At 4 wks, the treated areas showed complete healing, mostly unidentifiable endoscopically, with no signs of stricture, ulceration, or other significant findings.

The first 12 patients were treated with single energy application (single Tx). The subsequent 18 patients received double energy application (double Tx) and 14 have reached 24 wks. Clinically significant improvements in glycemic control were observed in these 14 patients. At 24 wks, mean HbA1c was 7.5% ± 1.1% vs. 8.4% ± 1.0% at baseline (p<0.01), FPG 7.5 ± 1.7 mmol/l vs. 9.8 ± 2.2 mmol/l (P<0.01), and HOMA-IR 4.5 ± 3.6 vs. 7.4 ± 3.3 (p<0.01). Weight loss was 5.1% ± 4.1% (p<0.01) at 24 wks. An energy dose-response relationship was observed between the single Tx and double Tx dose levels (P < 0.05) (Figure 1).

Conclusions
This first GI application of PEF in human demonstrated that the technology is feasible, safe, well tolerated by patients, and is associated with clinically meaningful improvement in glycemic control.
Background: Currently, there are several endoscopic procedures for the treatment of weight regain following Roux-en-Y gastric bypass (RYGB). These include argon plasma coagulation (APC), transoral outlet reduction via suturing (S-TORe) or plication (P-TORe). These procedures focus on reducing the size of the gastrojejunal anastomosis (GJA) and/or pouch. While their safety and efficacy have been established, there is no personalized approach to assist with procedure selection.

Aim: 1) To assess the efficacy of different endoscopic gastric bypass revision (EGBR) procedures 2) To construct an anatomy-based algorithm for the treatment of weight regain to optimize weight loss.

Methods: This is a single-center retrospective study of patients who underwent APC, S-TORe or P-TORe for the treatment of weight regain following RYGB. Patients who underwent EGBR using older suturing or plication platforms were excluded. Sensitivity analyses were performed to compare percent total weight loss (%TWL) at 12 months of different EGBR procedures at different GJA sizes. For pouch ≤ 5 cm, APC and S-TORe were compared as P-TORe is not typically performed given the length of the plication device. For pouch > 5 cm, S-TORe and P-TORe were compared as APC is not typically performed to reduce pouch volume. ANOVA was used for three group comparison and Student’s t-test for sensitivity analyses.

Results: 742 RYGB patients underwent 900 EGBR procedures. Of these, 191 (21%), 591 (66%) and 118 (13%) were APC, S-TORe and P-TORe, respectively. Baseline characteristics are shown in Table 1. At 12 months, patients in the APC, S-TORe and P-TORe experienced 8.1 ± 7.1 %TWL, 9.5 ± 8.7% TWL and 10.0 ± 8.5% TWL, respectively (p =0.25), with 70%, 72% and 63% experiencing at least 5% TWL (p = 0.50). There were no SAEs. Pouch ≤ 5 cm (APC vs S-TORe): On sensitivity analyses, with GJA < 18 mm, there was no difference in %TWL between APC and S-TORe (6.7 ± 7.7 %TWL vs 10.7 ± 11.1 %TWL, p=0.31). With GJA ≥ 18 mm, S-TORe yielded greater weight loss than APC (9.2 ± 8.2% TWL vs 5.3 ± 5.5% TWL, p=0.05). Pouch > 5 cm (S-TORe vs P-TORe): On sensitivity analyses, with GJA ≤ 25 mm, P-TORe yielded greater weight loss compared to S-TORe (13.2 ± 7.5%TWL vs 9.5 ± 9.1% TWL, p=0.04). With GJA > 25 mm, S-TORe yielded greater weight loss compared to P-TORe (17.1 ± 17.5% TWL vs -0.2 ± 7.5% TWL, p=0.03). Using results of the sensitivity analyses at different GJA size, an algorithm for the management of weight regain is constructed (Figure 1).

Conclusion: Endoscopic revision of RYGB in the treatment of weight regain can be individualized based on patient anatomy. For pouch ≤ 5 cm, S-TORe should be considered when GJA ≥ 18 mm, while either S-TORe or APC can be offered when GJA < 18 mm. For pouch > 5 cm, S-TORe should be considered when GJA > 25 mm, with P-TORe being offered when GJA ≤ 25 mm.
<b>Table 1</b>. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

Table 1. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

<b>Figure 1</b>. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Figure 1. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Introduction: Super-Obese patients presenting several comorbidities put foward a dilemma due to high perioperative adverse event rates. Although bariatric surgery remains to this moment the Gold standard of treatment while approaching those patients, not only as weight loss tools, but regarding their impact as metabolic procedures, only a small parcel accepts this option. Fear of complications even in then presence of extensive detailment opens a possibility for other solutions. Bariatric endoscopy proposes minimally invasive proceedings that can be an alternative not merely regarding weight loss but to the amelioration of comorbidities. Hence, it can postpone or even bypass surgery.
Objectives:
Methods: A cohort of 76 patients( mean age 43±7) with a BMI above 50 (51-63)was prospecticaly recruited and analysed retrospectively from February 2018 to January 2021. They were engaged to accomplish two consecutive endobariatric approaches. Firstly, a six-month nonadjustable intragastric balloon was placed, and at the time of the explant, an endoscopic sleeve Gastroplasty(Apollo Endosurgery) was executed.Weight loss results; Body mass composition (Inbody 720), elastography (Fibroscan, Echosens), HOMA-IR, Glicated Haemoglobin, Triglyceride levels, 24-Hour Ambulatory Blood Pressure Monitoring (ABPM), Sleep Apnea Disorders (polysommnography) were analysed by the student t test and the Wilcoxon test.
Results: 68 patients (55 females) completed the two consecutive procedures(3 early balloon removals; 2 not eligible for ESG at the time proposed and 3 opted for bariatric surgery )The average total body weight loss at IGB removal/ESG procedure was 19.74%(±4.67).ESG was accomplished with sucess on all, using an average of 5.6 sutures (4-7) with 15-22 bites per suture. One patient required hospitalization due to difficulty in extubation (2-day admission). No serious adverse event was reported. At 12 months, TBWL % was 32.57%.(+-9.79). 58 patients(75%), presented type 2 diabetes, and 88.2% had their medications decreased, with an average decrease in Hb1ac of 1.65%(+-1.22). Steatosis was present in 82% of patients (S2 score predominant;) and fibrosis in 21% of the group (F3 predominant).Improvements in 69.64 and 50 percent respectively(p<0.001) Sleep apnea in 69.11% with a betterment in 82.97%(p<0.001)ABPM melioration in all HBP bearers(p<0.001).
Conclusion: Although 18 Months were necessary to achieve those results, WL and betterment in comorbidities were similar to those reported after a surgical technique. The role of Endobariatrics broadens to other classes of patients rather than the predetermined originally to fill the gap between clinical and surgical approaches, targeting patients with a BMI of 30-40) and provides safe, effective and life-changing modifications.Therefore,could be offered as an alternative to those who can not or don not wish to undergo surgery.
Background and Aim: Current endoscopic bariatric therapies fail to achieve the same degree of weight loss and improvement in metabolic profile similar to laparoscopic sleeve gastrectomy (LSG) because they merely mimic its restrictive/anatomic aspects. Four essential requirements should be met to achieve the same anatomical and physiological benefits of surgery: (a) reducing gastric volume, (b) decreasing gastric compliance, (c) increasing gastric emptying, and (d) eradicating the hormonally active gastric mucosa. We aim to replicate the efficacy of LSG through a safe, simple, and effective endoscopic approach. We hypothesized that an endoscopic submucosal injection of a sclerosant agent can induce gastric remodeling that will mimic the effects of LSG.
Methods: To better simulate human physiology, we designed a 3D organ-on-a-chip (OoC) intestinal culture model to control cell
microenvironments and maintain tissue-specific functions. The OoC was constructed using co-culture of human intestinal epithelial cells (InEpC), human intestinal myofibroblasts (InMyoFib), and colon carcinoma cell line (Caco-2). The OoC was then treated with bleomycin (1, 1.5, and 2 ug/ml); minocycline (5,10, and 20 mg/ml); recombinant TGF-beta1 (10, 20, and 40 ng/ml), and negative control (Sodium Tetradecyl Sulfate;1000 uM). After initial cell viability testing, we performed immunostaining to detect the expression of fibrosis biomarkers: alpha-smooth muscle actin (alpha-SMA), and collagen-1 (Col-1). The examination was performed using high-resolution confocal microscopy
seven days after incubation.
Results: Bioprinted acellular tubes were constructed and cocultured with the selected cells successfully. The initial viability tests showed that most cells in the OoC culture survived the range of doses of the three candidate agents. However, there was a dose-dependent increase in the cell death ratio (Figure 1). Immunostaining showed that the three candidate agents induced a dose-dependent increase in the fibrotic reaction as evidenced by alpha-SMA actin and Col-1 expression compared to the control. The drug doses that produced the best outcome balance for cell death to the fibrotic reaction were 1.5 ug/ml for bleomycin, 10 mg/ml for minocycline, and 40 ng/ml for TGF-beta1 (Figure 2).
Conclusion: We successfully designed a 3D organ-on-a-chip intestinal culture model and induced an intense fibrotic reaction with bleomycin, minocycline, and recombinant TGF-beta1. This culture model represents a platform for future gastrointestinal research applications. We are currently leveraging our experience on this model to rodent and porcine animal models. The ultimate goal is to develop a single outpatient endoscopic procedure to treat obesity that does not require advanced endoscopic techniques and can be easily disseminated.
Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).


Saturday
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.
Background
Type 2 diabetes (T2D) affects 462 million people worldwide. Non-pharmacological interventions that can improve glycemic control in patients inadequately controlled with glucose-lowering medications (GLMs) have a potential to delay insulin initiation and modify disease progression. Duodenal mucosal regeneration (DMR) induced by thermal ablation has been associated with improved glycemic control in T2D patients.

Pulsed electric field (PEF) is a unique non-thermal modality that can selectively affect cells via electroporation. This first-in-human study evaluates the safety, feasibility and preliminary efficacy of endoscopic application of PEF to elicit DMR in T2D patients inadequately controlled on GLMs and is the first PEF application in gastrointestinal tract.

Method
This is an ongoing multicenter, open-label, treatment-only study. Key eligibility criteria are 18-70 years of age, history of T2D for ≤10 years, HbA1c of 7.5%-11.0%, BMI of 24 – 40 kg/m2, C-peptide ≥ 333 pmol/l, and on 1-4 non-insulin GLMs. The primary endpoint is the incidence of device- or procedure-related serious adverse events (SAEs) at 12 wks. Secondary endpoints include technical success and changes in glycemic control at 24 wks. The procedure is performed endoscopically using the ReCET™ device (Endogenex Inc.). Patients are followed for 48 wks, with endoscopic follow up at 4 wks. The GLMs are maintained stable for ≥12 wks before and ≥24 wks after the procedure.

Results
To date, 30 patients have been enrolled (Table 1). Technical success was 100%, with a mean treated length of 11.0 ± 1.9 cm, and median procedure time of 59 min (IQR 42 – 78). No device/procedure-related SAEs occurred. Forty-five device/procedure-related adverse events (AEs) were reported in 23/30 patients. Most reported AEs were sore throat (17/30) and transient diarrhea (9/30). AEs were mild (80%) or moderate (20%) in severity. At 4 wks, the treated areas showed complete healing, mostly unidentifiable endoscopically, with no signs of stricture, ulceration, or other significant findings.

The first 12 patients were treated with single energy application (single Tx). The subsequent 18 patients received double energy application (double Tx) and 14 have reached 24 wks. Clinically significant improvements in glycemic control were observed in these 14 patients. At 24 wks, mean HbA1c was 7.5% ± 1.1% vs. 8.4% ± 1.0% at baseline (p<0.01), FPG 7.5 ± 1.7 mmol/l vs. 9.8 ± 2.2 mmol/l (P<0.01), and HOMA-IR 4.5 ± 3.6 vs. 7.4 ± 3.3 (p<0.01). Weight loss was 5.1% ± 4.1% (p<0.01) at 24 wks. An energy dose-response relationship was observed between the single Tx and double Tx dose levels (P < 0.05) (Figure 1).

Conclusions
This first GI application of PEF in human demonstrated that the technology is feasible, safe, well tolerated by patients, and is associated with clinically meaningful improvement in glycemic control.
Background: Currently, there are several endoscopic procedures for the treatment of weight regain following Roux-en-Y gastric bypass (RYGB). These include argon plasma coagulation (APC), transoral outlet reduction via suturing (S-TORe) or plication (P-TORe). These procedures focus on reducing the size of the gastrojejunal anastomosis (GJA) and/or pouch. While their safety and efficacy have been established, there is no personalized approach to assist with procedure selection.

Aim: 1) To assess the efficacy of different endoscopic gastric bypass revision (EGBR) procedures 2) To construct an anatomy-based algorithm for the treatment of weight regain to optimize weight loss.

Methods: This is a single-center retrospective study of patients who underwent APC, S-TORe or P-TORe for the treatment of weight regain following RYGB. Patients who underwent EGBR using older suturing or plication platforms were excluded. Sensitivity analyses were performed to compare percent total weight loss (%TWL) at 12 months of different EGBR procedures at different GJA sizes. For pouch ≤ 5 cm, APC and S-TORe were compared as P-TORe is not typically performed given the length of the plication device. For pouch > 5 cm, S-TORe and P-TORe were compared as APC is not typically performed to reduce pouch volume. ANOVA was used for three group comparison and Student’s t-test for sensitivity analyses.

Results: 742 RYGB patients underwent 900 EGBR procedures. Of these, 191 (21%), 591 (66%) and 118 (13%) were APC, S-TORe and P-TORe, respectively. Baseline characteristics are shown in Table 1. At 12 months, patients in the APC, S-TORe and P-TORe experienced 8.1 ± 7.1 %TWL, 9.5 ± 8.7% TWL and 10.0 ± 8.5% TWL, respectively (p =0.25), with 70%, 72% and 63% experiencing at least 5% TWL (p = 0.50). There were no SAEs. Pouch ≤ 5 cm (APC vs S-TORe): On sensitivity analyses, with GJA < 18 mm, there was no difference in %TWL between APC and S-TORe (6.7 ± 7.7 %TWL vs 10.7 ± 11.1 %TWL, p=0.31). With GJA ≥ 18 mm, S-TORe yielded greater weight loss than APC (9.2 ± 8.2% TWL vs 5.3 ± 5.5% TWL, p=0.05). Pouch > 5 cm (S-TORe vs P-TORe): On sensitivity analyses, with GJA ≤ 25 mm, P-TORe yielded greater weight loss compared to S-TORe (13.2 ± 7.5%TWL vs 9.5 ± 9.1% TWL, p=0.04). With GJA > 25 mm, S-TORe yielded greater weight loss compared to P-TORe (17.1 ± 17.5% TWL vs -0.2 ± 7.5% TWL, p=0.03). Using results of the sensitivity analyses at different GJA size, an algorithm for the management of weight regain is constructed (Figure 1).

Conclusion: Endoscopic revision of RYGB in the treatment of weight regain can be individualized based on patient anatomy. For pouch ≤ 5 cm, S-TORe should be considered when GJA ≥ 18 mm, while either S-TORe or APC can be offered when GJA < 18 mm. For pouch > 5 cm, S-TORe should be considered when GJA > 25 mm, with P-TORe being offered when GJA ≤ 25 mm.
<b>Table 1</b>. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

Table 1. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

<b>Figure 1</b>. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Figure 1. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Introduction: Super-Obese patients presenting several comorbidities put foward a dilemma due to high perioperative adverse event rates. Although bariatric surgery remains to this moment the Gold standard of treatment while approaching those patients, not only as weight loss tools, but regarding their impact as metabolic procedures, only a small parcel accepts this option. Fear of complications even in then presence of extensive detailment opens a possibility for other solutions. Bariatric endoscopy proposes minimally invasive proceedings that can be an alternative not merely regarding weight loss but to the amelioration of comorbidities. Hence, it can postpone or even bypass surgery.
Objectives:
Methods: A cohort of 76 patients( mean age 43±7) with a BMI above 50 (51-63)was prospecticaly recruited and analysed retrospectively from February 2018 to January 2021. They were engaged to accomplish two consecutive endobariatric approaches. Firstly, a six-month nonadjustable intragastric balloon was placed, and at the time of the explant, an endoscopic sleeve Gastroplasty(Apollo Endosurgery) was executed.Weight loss results; Body mass composition (Inbody 720), elastography (Fibroscan, Echosens), HOMA-IR, Glicated Haemoglobin, Triglyceride levels, 24-Hour Ambulatory Blood Pressure Monitoring (ABPM), Sleep Apnea Disorders (polysommnography) were analysed by the student t test and the Wilcoxon test.
Results: 68 patients (55 females) completed the two consecutive procedures(3 early balloon removals; 2 not eligible for ESG at the time proposed and 3 opted for bariatric surgery )The average total body weight loss at IGB removal/ESG procedure was 19.74%(±4.67).ESG was accomplished with sucess on all, using an average of 5.6 sutures (4-7) with 15-22 bites per suture. One patient required hospitalization due to difficulty in extubation (2-day admission). No serious adverse event was reported. At 12 months, TBWL % was 32.57%.(+-9.79). 58 patients(75%), presented type 2 diabetes, and 88.2% had their medications decreased, with an average decrease in Hb1ac of 1.65%(+-1.22). Steatosis was present in 82% of patients (S2 score predominant;) and fibrosis in 21% of the group (F3 predominant).Improvements in 69.64 and 50 percent respectively(p<0.001) Sleep apnea in 69.11% with a betterment in 82.97%(p<0.001)ABPM melioration in all HBP bearers(p<0.001).
Conclusion: Although 18 Months were necessary to achieve those results, WL and betterment in comorbidities were similar to those reported after a surgical technique. The role of Endobariatrics broadens to other classes of patients rather than the predetermined originally to fill the gap between clinical and surgical approaches, targeting patients with a BMI of 30-40) and provides safe, effective and life-changing modifications.Therefore,could be offered as an alternative to those who can not or don not wish to undergo surgery.
Background and Aim: Current endoscopic bariatric therapies fail to achieve the same degree of weight loss and improvement in metabolic profile similar to laparoscopic sleeve gastrectomy (LSG) because they merely mimic its restrictive/anatomic aspects. Four essential requirements should be met to achieve the same anatomical and physiological benefits of surgery: (a) reducing gastric volume, (b) decreasing gastric compliance, (c) increasing gastric emptying, and (d) eradicating the hormonally active gastric mucosa. We aim to replicate the efficacy of LSG through a safe, simple, and effective endoscopic approach. We hypothesized that an endoscopic submucosal injection of a sclerosant agent can induce gastric remodeling that will mimic the effects of LSG.
Methods: To better simulate human physiology, we designed a 3D organ-on-a-chip (OoC) intestinal culture model to control cell
microenvironments and maintain tissue-specific functions. The OoC was constructed using co-culture of human intestinal epithelial cells (InEpC), human intestinal myofibroblasts (InMyoFib), and colon carcinoma cell line (Caco-2). The OoC was then treated with bleomycin (1, 1.5, and 2 ug/ml); minocycline (5,10, and 20 mg/ml); recombinant TGF-beta1 (10, 20, and 40 ng/ml), and negative control (Sodium Tetradecyl Sulfate;1000 uM). After initial cell viability testing, we performed immunostaining to detect the expression of fibrosis biomarkers: alpha-smooth muscle actin (alpha-SMA), and collagen-1 (Col-1). The examination was performed using high-resolution confocal microscopy
seven days after incubation.
Results: Bioprinted acellular tubes were constructed and cocultured with the selected cells successfully. The initial viability tests showed that most cells in the OoC culture survived the range of doses of the three candidate agents. However, there was a dose-dependent increase in the cell death ratio (Figure 1). Immunostaining showed that the three candidate agents induced a dose-dependent increase in the fibrotic reaction as evidenced by alpha-SMA actin and Col-1 expression compared to the control. The drug doses that produced the best outcome balance for cell death to the fibrotic reaction were 1.5 ug/ml for bleomycin, 10 mg/ml for minocycline, and 40 ng/ml for TGF-beta1 (Figure 2).
Conclusion: We successfully designed a 3D organ-on-a-chip intestinal culture model and induced an intense fibrotic reaction with bleomycin, minocycline, and recombinant TGF-beta1. This culture model represents a platform for future gastrointestinal research applications. We are currently leveraging our experience on this model to rodent and porcine animal models. The ultimate goal is to develop a single outpatient endoscopic procedure to treat obesity that does not require advanced endoscopic techniques and can be easily disseminated.
Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).

Background: Analysis from the Centres for Disease Control and Preventions (CMS) suggests the prevalence of obesity in the U.S. was 41.9% in 2017, and is expected to increase to 50% by 2030. Obesity is a major risk factor for multiple chronic diseases (such as type II diabetes and cardiovascular disease) and can lead to reduced quality of life as well as increased risk of death. Lifestyle modification (LM) has traditionally been a first-line treatment for adults with obesity but recent guidelines recommend bariatric intervention. Endoscopic sleeve gastroplasty (ESG) is a reversible, endoluminal organsparing bariatric procedure that has demonstrated sustained weight loss in people with obesity. The MERIT randomized, controlled trial (RCT) recently showed that ESG with concomitant LM (‘ESG’) led to significant and durable additional excess weight loss versus LM alone (‘LM’) among adults with class I (BMI 30.0-34.9 kg/m2) and class II obesity (BMI 35.0-39.9 kg/m2) as well as improvements in obesity-related comorbidities including type 2 diabetes.
Aim: We aimed to provide the first US cost-utility analysis of ESG vs LM among people with class II obesity.
Methods: The model was built from the perspective of the commercial US payor and methods were aligned with ISPOR recommendations. We used a 6-state Markov model that included 5 BMI-based health states and an additional absorbing death state (Figure 1). Clinical parameters were informed the MERIT Trial. Six-month cycles were used in the first year to reflect the significant and rapid weight loss observed with ESG and annual cycles were used thereafter. Estimates of utility for each health state, disutilities for adverse events, and the incidence of obesity-related comorbidities were based on published literature. One-way sensitivity and probabilistic sensitivity analyses were undertaken.
Results: ESG is highly cost-effective compared to LM from the US perspective. The base-case incremental cost-effectiveness ratio (ICER) for ESG vs LM was $9,281/QALY. The estimated incidence of diabetes had the largest impact on the ICER in one-way sensitivity analyses, though ESG was consistently cost effective across all sensitivity and dominant (cost-saving and improving quality of life) in scenario analyses with no upper bound ICER estimate exceeding $23,000/QALY gained, at a willingness to pay ratio of $50,000/QALY.
Conclusion: Compared with LM alone, ESG is a highly cost-effective treatment option for adults and should be used in selected patients requiring bariatric intervention from the US commercial perspective. Further clinical studies are required the cost effectiveness of ESG with other bariatric obesity interventions including LSG and pharmacological agents.
Cost Utility Model Structure

Cost Utility Model Structure


Saturday
10:00am - 10:02am EDT - May 6, 2023 | Room: S502 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.
Background
Type 2 diabetes (T2D) affects 462 million people worldwide. Non-pharmacological interventions that can improve glycemic control in patients inadequately controlled with glucose-lowering medications (GLMs) have a potential to delay insulin initiation and modify disease progression. Duodenal mucosal regeneration (DMR) induced by thermal ablation has been associated with improved glycemic control in T2D patients.

Pulsed electric field (PEF) is a unique non-thermal modality that can selectively affect cells via electroporation. This first-in-human study evaluates the safety, feasibility and preliminary efficacy of endoscopic application of PEF to elicit DMR in T2D patients inadequately controlled on GLMs and is the first PEF application in gastrointestinal tract.

Method
This is an ongoing multicenter, open-label, treatment-only study. Key eligibility criteria are 18-70 years of age, history of T2D for ≤10 years, HbA1c of 7.5%-11.0%, BMI of 24 – 40 kg/m2, C-peptide ≥ 333 pmol/l, and on 1-4 non-insulin GLMs. The primary endpoint is the incidence of device- or procedure-related serious adverse events (SAEs) at 12 wks. Secondary endpoints include technical success and changes in glycemic control at 24 wks. The procedure is performed endoscopically using the ReCET™ device (Endogenex Inc.). Patients are followed for 48 wks, with endoscopic follow up at 4 wks. The GLMs are maintained stable for ≥12 wks before and ≥24 wks after the procedure.

Results
To date, 30 patients have been enrolled (Table 1). Technical success was 100%, with a mean treated length of 11.0 ± 1.9 cm, and median procedure time of 59 min (IQR 42 – 78). No device/procedure-related SAEs occurred. Forty-five device/procedure-related adverse events (AEs) were reported in 23/30 patients. Most reported AEs were sore throat (17/30) and transient diarrhea (9/30). AEs were mild (80%) or moderate (20%) in severity. At 4 wks, the treated areas showed complete healing, mostly unidentifiable endoscopically, with no signs of stricture, ulceration, or other significant findings.

The first 12 patients were treated with single energy application (single Tx). The subsequent 18 patients received double energy application (double Tx) and 14 have reached 24 wks. Clinically significant improvements in glycemic control were observed in these 14 patients. At 24 wks, mean HbA1c was 7.5% ± 1.1% vs. 8.4% ± 1.0% at baseline (p<0.01), FPG 7.5 ± 1.7 mmol/l vs. 9.8 ± 2.2 mmol/l (P<0.01), and HOMA-IR 4.5 ± 3.6 vs. 7.4 ± 3.3 (p<0.01). Weight loss was 5.1% ± 4.1% (p<0.01) at 24 wks. An energy dose-response relationship was observed between the single Tx and double Tx dose levels (P < 0.05) (Figure 1).

Conclusions
This first GI application of PEF in human demonstrated that the technology is feasible, safe, well tolerated by patients, and is associated with clinically meaningful improvement in glycemic control.
Background: Currently, there are several endoscopic procedures for the treatment of weight regain following Roux-en-Y gastric bypass (RYGB). These include argon plasma coagulation (APC), transoral outlet reduction via suturing (S-TORe) or plication (P-TORe). These procedures focus on reducing the size of the gastrojejunal anastomosis (GJA) and/or pouch. While their safety and efficacy have been established, there is no personalized approach to assist with procedure selection.

Aim: 1) To assess the efficacy of different endoscopic gastric bypass revision (EGBR) procedures 2) To construct an anatomy-based algorithm for the treatment of weight regain to optimize weight loss.

Methods: This is a single-center retrospective study of patients who underwent APC, S-TORe or P-TORe for the treatment of weight regain following RYGB. Patients who underwent EGBR using older suturing or plication platforms were excluded. Sensitivity analyses were performed to compare percent total weight loss (%TWL) at 12 months of different EGBR procedures at different GJA sizes. For pouch ≤ 5 cm, APC and S-TORe were compared as P-TORe is not typically performed given the length of the plication device. For pouch > 5 cm, S-TORe and P-TORe were compared as APC is not typically performed to reduce pouch volume. ANOVA was used for three group comparison and Student’s t-test for sensitivity analyses.

Results: 742 RYGB patients underwent 900 EGBR procedures. Of these, 191 (21%), 591 (66%) and 118 (13%) were APC, S-TORe and P-TORe, respectively. Baseline characteristics are shown in Table 1. At 12 months, patients in the APC, S-TORe and P-TORe experienced 8.1 ± 7.1 %TWL, 9.5 ± 8.7% TWL and 10.0 ± 8.5% TWL, respectively (p =0.25), with 70%, 72% and 63% experiencing at least 5% TWL (p = 0.50). There were no SAEs. Pouch ≤ 5 cm (APC vs S-TORe): On sensitivity analyses, with GJA < 18 mm, there was no difference in %TWL between APC and S-TORe (6.7 ± 7.7 %TWL vs 10.7 ± 11.1 %TWL, p=0.31). With GJA ≥ 18 mm, S-TORe yielded greater weight loss than APC (9.2 ± 8.2% TWL vs 5.3 ± 5.5% TWL, p=0.05). Pouch > 5 cm (S-TORe vs P-TORe): On sensitivity analyses, with GJA ≤ 25 mm, P-TORe yielded greater weight loss compared to S-TORe (13.2 ± 7.5%TWL vs 9.5 ± 9.1% TWL, p=0.04). With GJA > 25 mm, S-TORe yielded greater weight loss compared to P-TORe (17.1 ± 17.5% TWL vs -0.2 ± 7.5% TWL, p=0.03). Using results of the sensitivity analyses at different GJA size, an algorithm for the management of weight regain is constructed (Figure 1).

Conclusion: Endoscopic revision of RYGB in the treatment of weight regain can be individualized based on patient anatomy. For pouch ≤ 5 cm, S-TORe should be considered when GJA ≥ 18 mm, while either S-TORe or APC can be offered when GJA < 18 mm. For pouch > 5 cm, S-TORe should be considered when GJA > 25 mm, with P-TORe being offered when GJA ≤ 25 mm.
<b>Table 1</b>. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

Table 1. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

<b>Figure 1</b>. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Figure 1. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Introduction: Super-Obese patients presenting several comorbidities put foward a dilemma due to high perioperative adverse event rates. Although bariatric surgery remains to this moment the Gold standard of treatment while approaching those patients, not only as weight loss tools, but regarding their impact as metabolic procedures, only a small parcel accepts this option. Fear of complications even in then presence of extensive detailment opens a possibility for other solutions. Bariatric endoscopy proposes minimally invasive proceedings that can be an alternative not merely regarding weight loss but to the amelioration of comorbidities. Hence, it can postpone or even bypass surgery.
Objectives:
Methods: A cohort of 76 patients( mean age 43±7) with a BMI above 50 (51-63)was prospecticaly recruited and analysed retrospectively from February 2018 to January 2021. They were engaged to accomplish two consecutive endobariatric approaches. Firstly, a six-month nonadjustable intragastric balloon was placed, and at the time of the explant, an endoscopic sleeve Gastroplasty(Apollo Endosurgery) was executed.Weight loss results; Body mass composition (Inbody 720), elastography (Fibroscan, Echosens), HOMA-IR, Glicated Haemoglobin, Triglyceride levels, 24-Hour Ambulatory Blood Pressure Monitoring (ABPM), Sleep Apnea Disorders (polysommnography) were analysed by the student t test and the Wilcoxon test.
Results: 68 patients (55 females) completed the two consecutive procedures(3 early balloon removals; 2 not eligible for ESG at the time proposed and 3 opted for bariatric surgery )The average total body weight loss at IGB removal/ESG procedure was 19.74%(±4.67).ESG was accomplished with sucess on all, using an average of 5.6 sutures (4-7) with 15-22 bites per suture. One patient required hospitalization due to difficulty in extubation (2-day admission). No serious adverse event was reported. At 12 months, TBWL % was 32.57%.(+-9.79). 58 patients(75%), presented type 2 diabetes, and 88.2% had their medications decreased, with an average decrease in Hb1ac of 1.65%(+-1.22). Steatosis was present in 82% of patients (S2 score predominant;) and fibrosis in 21% of the group (F3 predominant).Improvements in 69.64 and 50 percent respectively(p<0.001) Sleep apnea in 69.11% with a betterment in 82.97%(p<0.001)ABPM melioration in all HBP bearers(p<0.001).
Conclusion: Although 18 Months were necessary to achieve those results, WL and betterment in comorbidities were similar to those reported after a surgical technique. The role of Endobariatrics broadens to other classes of patients rather than the predetermined originally to fill the gap between clinical and surgical approaches, targeting patients with a BMI of 30-40) and provides safe, effective and life-changing modifications.Therefore,could be offered as an alternative to those who can not or don not wish to undergo surgery.
Background and Aim: Current endoscopic bariatric therapies fail to achieve the same degree of weight loss and improvement in metabolic profile similar to laparoscopic sleeve gastrectomy (LSG) because they merely mimic its restrictive/anatomic aspects. Four essential requirements should be met to achieve the same anatomical and physiological benefits of surgery: (a) reducing gastric volume, (b) decreasing gastric compliance, (c) increasing gastric emptying, and (d) eradicating the hormonally active gastric mucosa. We aim to replicate the efficacy of LSG through a safe, simple, and effective endoscopic approach. We hypothesized that an endoscopic submucosal injection of a sclerosant agent can induce gastric remodeling that will mimic the effects of LSG.
Methods: To better simulate human physiology, we designed a 3D organ-on-a-chip (OoC) intestinal culture model to control cell
microenvironments and maintain tissue-specific functions. The OoC was constructed using co-culture of human intestinal epithelial cells (InEpC), human intestinal myofibroblasts (InMyoFib), and colon carcinoma cell line (Caco-2). The OoC was then treated with bleomycin (1, 1.5, and 2 ug/ml); minocycline (5,10, and 20 mg/ml); recombinant TGF-beta1 (10, 20, and 40 ng/ml), and negative control (Sodium Tetradecyl Sulfate;1000 uM). After initial cell viability testing, we performed immunostaining to detect the expression of fibrosis biomarkers: alpha-smooth muscle actin (alpha-SMA), and collagen-1 (Col-1). The examination was performed using high-resolution confocal microscopy
seven days after incubation.
Results: Bioprinted acellular tubes were constructed and cocultured with the selected cells successfully. The initial viability tests showed that most cells in the OoC culture survived the range of doses of the three candidate agents. However, there was a dose-dependent increase in the cell death ratio (Figure 1). Immunostaining showed that the three candidate agents induced a dose-dependent increase in the fibrotic reaction as evidenced by alpha-SMA actin and Col-1 expression compared to the control. The drug doses that produced the best outcome balance for cell death to the fibrotic reaction were 1.5 ug/ml for bleomycin, 10 mg/ml for minocycline, and 40 ng/ml for TGF-beta1 (Figure 2).
Conclusion: We successfully designed a 3D organ-on-a-chip intestinal culture model and induced an intense fibrotic reaction with bleomycin, minocycline, and recombinant TGF-beta1. This culture model represents a platform for future gastrointestinal research applications. We are currently leveraging our experience on this model to rodent and porcine animal models. The ultimate goal is to develop a single outpatient endoscopic procedure to treat obesity that does not require advanced endoscopic techniques and can be easily disseminated.
Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).

Background: Analysis from the Centres for Disease Control and Preventions (CMS) suggests the prevalence of obesity in the U.S. was 41.9% in 2017, and is expected to increase to 50% by 2030. Obesity is a major risk factor for multiple chronic diseases (such as type II diabetes and cardiovascular disease) and can lead to reduced quality of life as well as increased risk of death. Lifestyle modification (LM) has traditionally been a first-line treatment for adults with obesity but recent guidelines recommend bariatric intervention. Endoscopic sleeve gastroplasty (ESG) is a reversible, endoluminal organsparing bariatric procedure that has demonstrated sustained weight loss in people with obesity. The MERIT randomized, controlled trial (RCT) recently showed that ESG with concomitant LM (‘ESG’) led to significant and durable additional excess weight loss versus LM alone (‘LM’) among adults with class I (BMI 30.0-34.9 kg/m2) and class II obesity (BMI 35.0-39.9 kg/m2) as well as improvements in obesity-related comorbidities including type 2 diabetes.
Aim: We aimed to provide the first US cost-utility analysis of ESG vs LM among people with class II obesity.
Methods: The model was built from the perspective of the commercial US payor and methods were aligned with ISPOR recommendations. We used a 6-state Markov model that included 5 BMI-based health states and an additional absorbing death state (Figure 1). Clinical parameters were informed the MERIT Trial. Six-month cycles were used in the first year to reflect the significant and rapid weight loss observed with ESG and annual cycles were used thereafter. Estimates of utility for each health state, disutilities for adverse events, and the incidence of obesity-related comorbidities were based on published literature. One-way sensitivity and probabilistic sensitivity analyses were undertaken.
Results: ESG is highly cost-effective compared to LM from the US perspective. The base-case incremental cost-effectiveness ratio (ICER) for ESG vs LM was $9,281/QALY. The estimated incidence of diabetes had the largest impact on the ICER in one-way sensitivity analyses, though ESG was consistently cost effective across all sensitivity and dominant (cost-saving and improving quality of life) in scenario analyses with no upper bound ICER estimate exceeding $23,000/QALY gained, at a willingness to pay ratio of $50,000/QALY.
Conclusion: Compared with LM alone, ESG is a highly cost-effective treatment option for adults and should be used in selected patients requiring bariatric intervention from the US commercial perspective. Further clinical studies are required the cost effectiveness of ESG with other bariatric obesity interventions including LSG and pharmacological agents.
Cost Utility Model Structure

Cost Utility Model Structure


Saturday
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.
Background
Type 2 diabetes (T2D) affects 462 million people worldwide. Non-pharmacological interventions that can improve glycemic control in patients inadequately controlled with glucose-lowering medications (GLMs) have a potential to delay insulin initiation and modify disease progression. Duodenal mucosal regeneration (DMR) induced by thermal ablation has been associated with improved glycemic control in T2D patients.

Pulsed electric field (PEF) is a unique non-thermal modality that can selectively affect cells via electroporation. This first-in-human study evaluates the safety, feasibility and preliminary efficacy of endoscopic application of PEF to elicit DMR in T2D patients inadequately controlled on GLMs and is the first PEF application in gastrointestinal tract.

Method
This is an ongoing multicenter, open-label, treatment-only study. Key eligibility criteria are 18-70 years of age, history of T2D for ≤10 years, HbA1c of 7.5%-11.0%, BMI of 24 – 40 kg/m2, C-peptide ≥ 333 pmol/l, and on 1-4 non-insulin GLMs. The primary endpoint is the incidence of device- or procedure-related serious adverse events (SAEs) at 12 wks. Secondary endpoints include technical success and changes in glycemic control at 24 wks. The procedure is performed endoscopically using the ReCET™ device (Endogenex Inc.). Patients are followed for 48 wks, with endoscopic follow up at 4 wks. The GLMs are maintained stable for ≥12 wks before and ≥24 wks after the procedure.

Results
To date, 30 patients have been enrolled (Table 1). Technical success was 100%, with a mean treated length of 11.0 ± 1.9 cm, and median procedure time of 59 min (IQR 42 – 78). No device/procedure-related SAEs occurred. Forty-five device/procedure-related adverse events (AEs) were reported in 23/30 patients. Most reported AEs were sore throat (17/30) and transient diarrhea (9/30). AEs were mild (80%) or moderate (20%) in severity. At 4 wks, the treated areas showed complete healing, mostly unidentifiable endoscopically, with no signs of stricture, ulceration, or other significant findings.

The first 12 patients were treated with single energy application (single Tx). The subsequent 18 patients received double energy application (double Tx) and 14 have reached 24 wks. Clinically significant improvements in glycemic control were observed in these 14 patients. At 24 wks, mean HbA1c was 7.5% ± 1.1% vs. 8.4% ± 1.0% at baseline (p<0.01), FPG 7.5 ± 1.7 mmol/l vs. 9.8 ± 2.2 mmol/l (P<0.01), and HOMA-IR 4.5 ± 3.6 vs. 7.4 ± 3.3 (p<0.01). Weight loss was 5.1% ± 4.1% (p<0.01) at 24 wks. An energy dose-response relationship was observed between the single Tx and double Tx dose levels (P < 0.05) (Figure 1).

Conclusions
This first GI application of PEF in human demonstrated that the technology is feasible, safe, well tolerated by patients, and is associated with clinically meaningful improvement in glycemic control.
Background: Currently, there are several endoscopic procedures for the treatment of weight regain following Roux-en-Y gastric bypass (RYGB). These include argon plasma coagulation (APC), transoral outlet reduction via suturing (S-TORe) or plication (P-TORe). These procedures focus on reducing the size of the gastrojejunal anastomosis (GJA) and/or pouch. While their safety and efficacy have been established, there is no personalized approach to assist with procedure selection.

Aim: 1) To assess the efficacy of different endoscopic gastric bypass revision (EGBR) procedures 2) To construct an anatomy-based algorithm for the treatment of weight regain to optimize weight loss.

Methods: This is a single-center retrospective study of patients who underwent APC, S-TORe or P-TORe for the treatment of weight regain following RYGB. Patients who underwent EGBR using older suturing or plication platforms were excluded. Sensitivity analyses were performed to compare percent total weight loss (%TWL) at 12 months of different EGBR procedures at different GJA sizes. For pouch ≤ 5 cm, APC and S-TORe were compared as P-TORe is not typically performed given the length of the plication device. For pouch > 5 cm, S-TORe and P-TORe were compared as APC is not typically performed to reduce pouch volume. ANOVA was used for three group comparison and Student’s t-test for sensitivity analyses.

Results: 742 RYGB patients underwent 900 EGBR procedures. Of these, 191 (21%), 591 (66%) and 118 (13%) were APC, S-TORe and P-TORe, respectively. Baseline characteristics are shown in Table 1. At 12 months, patients in the APC, S-TORe and P-TORe experienced 8.1 ± 7.1 %TWL, 9.5 ± 8.7% TWL and 10.0 ± 8.5% TWL, respectively (p =0.25), with 70%, 72% and 63% experiencing at least 5% TWL (p = 0.50). There were no SAEs. Pouch ≤ 5 cm (APC vs S-TORe): On sensitivity analyses, with GJA < 18 mm, there was no difference in %TWL between APC and S-TORe (6.7 ± 7.7 %TWL vs 10.7 ± 11.1 %TWL, p=0.31). With GJA ≥ 18 mm, S-TORe yielded greater weight loss than APC (9.2 ± 8.2% TWL vs 5.3 ± 5.5% TWL, p=0.05). Pouch > 5 cm (S-TORe vs P-TORe): On sensitivity analyses, with GJA ≤ 25 mm, P-TORe yielded greater weight loss compared to S-TORe (13.2 ± 7.5%TWL vs 9.5 ± 9.1% TWL, p=0.04). With GJA > 25 mm, S-TORe yielded greater weight loss compared to P-TORe (17.1 ± 17.5% TWL vs -0.2 ± 7.5% TWL, p=0.03). Using results of the sensitivity analyses at different GJA size, an algorithm for the management of weight regain is constructed (Figure 1).

Conclusion: Endoscopic revision of RYGB in the treatment of weight regain can be individualized based on patient anatomy. For pouch ≤ 5 cm, S-TORe should be considered when GJA ≥ 18 mm, while either S-TORe or APC can be offered when GJA < 18 mm. For pouch > 5 cm, S-TORe should be considered when GJA > 25 mm, with P-TORe being offered when GJA ≤ 25 mm.
<b>Table 1</b>. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

Table 1. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

<b>Figure 1</b>. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Figure 1. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Introduction: Super-Obese patients presenting several comorbidities put foward a dilemma due to high perioperative adverse event rates. Although bariatric surgery remains to this moment the Gold standard of treatment while approaching those patients, not only as weight loss tools, but regarding their impact as metabolic procedures, only a small parcel accepts this option. Fear of complications even in then presence of extensive detailment opens a possibility for other solutions. Bariatric endoscopy proposes minimally invasive proceedings that can be an alternative not merely regarding weight loss but to the amelioration of comorbidities. Hence, it can postpone or even bypass surgery.
Objectives:
Methods: A cohort of 76 patients( mean age 43±7) with a BMI above 50 (51-63)was prospecticaly recruited and analysed retrospectively from February 2018 to January 2021. They were engaged to accomplish two consecutive endobariatric approaches. Firstly, a six-month nonadjustable intragastric balloon was placed, and at the time of the explant, an endoscopic sleeve Gastroplasty(Apollo Endosurgery) was executed.Weight loss results; Body mass composition (Inbody 720), elastography (Fibroscan, Echosens), HOMA-IR, Glicated Haemoglobin, Triglyceride levels, 24-Hour Ambulatory Blood Pressure Monitoring (ABPM), Sleep Apnea Disorders (polysommnography) were analysed by the student t test and the Wilcoxon test.
Results: 68 patients (55 females) completed the two consecutive procedures(3 early balloon removals; 2 not eligible for ESG at the time proposed and 3 opted for bariatric surgery )The average total body weight loss at IGB removal/ESG procedure was 19.74%(±4.67).ESG was accomplished with sucess on all, using an average of 5.6 sutures (4-7) with 15-22 bites per suture. One patient required hospitalization due to difficulty in extubation (2-day admission). No serious adverse event was reported. At 12 months, TBWL % was 32.57%.(+-9.79). 58 patients(75%), presented type 2 diabetes, and 88.2% had their medications decreased, with an average decrease in Hb1ac of 1.65%(+-1.22). Steatosis was present in 82% of patients (S2 score predominant;) and fibrosis in 21% of the group (F3 predominant).Improvements in 69.64 and 50 percent respectively(p<0.001) Sleep apnea in 69.11% with a betterment in 82.97%(p<0.001)ABPM melioration in all HBP bearers(p<0.001).
Conclusion: Although 18 Months were necessary to achieve those results, WL and betterment in comorbidities were similar to those reported after a surgical technique. The role of Endobariatrics broadens to other classes of patients rather than the predetermined originally to fill the gap between clinical and surgical approaches, targeting patients with a BMI of 30-40) and provides safe, effective and life-changing modifications.Therefore,could be offered as an alternative to those who can not or don not wish to undergo surgery.
Background and Aim: Current endoscopic bariatric therapies fail to achieve the same degree of weight loss and improvement in metabolic profile similar to laparoscopic sleeve gastrectomy (LSG) because they merely mimic its restrictive/anatomic aspects. Four essential requirements should be met to achieve the same anatomical and physiological benefits of surgery: (a) reducing gastric volume, (b) decreasing gastric compliance, (c) increasing gastric emptying, and (d) eradicating the hormonally active gastric mucosa. We aim to replicate the efficacy of LSG through a safe, simple, and effective endoscopic approach. We hypothesized that an endoscopic submucosal injection of a sclerosant agent can induce gastric remodeling that will mimic the effects of LSG.
Methods: To better simulate human physiology, we designed a 3D organ-on-a-chip (OoC) intestinal culture model to control cell
microenvironments and maintain tissue-specific functions. The OoC was constructed using co-culture of human intestinal epithelial cells (InEpC), human intestinal myofibroblasts (InMyoFib), and colon carcinoma cell line (Caco-2). The OoC was then treated with bleomycin (1, 1.5, and 2 ug/ml); minocycline (5,10, and 20 mg/ml); recombinant TGF-beta1 (10, 20, and 40 ng/ml), and negative control (Sodium Tetradecyl Sulfate;1000 uM). After initial cell viability testing, we performed immunostaining to detect the expression of fibrosis biomarkers: alpha-smooth muscle actin (alpha-SMA), and collagen-1 (Col-1). The examination was performed using high-resolution confocal microscopy
seven days after incubation.
Results: Bioprinted acellular tubes were constructed and cocultured with the selected cells successfully. The initial viability tests showed that most cells in the OoC culture survived the range of doses of the three candidate agents. However, there was a dose-dependent increase in the cell death ratio (Figure 1). Immunostaining showed that the three candidate agents induced a dose-dependent increase in the fibrotic reaction as evidenced by alpha-SMA actin and Col-1 expression compared to the control. The drug doses that produced the best outcome balance for cell death to the fibrotic reaction were 1.5 ug/ml for bleomycin, 10 mg/ml for minocycline, and 40 ng/ml for TGF-beta1 (Figure 2).
Conclusion: We successfully designed a 3D organ-on-a-chip intestinal culture model and induced an intense fibrotic reaction with bleomycin, minocycline, and recombinant TGF-beta1. This culture model represents a platform for future gastrointestinal research applications. We are currently leveraging our experience on this model to rodent and porcine animal models. The ultimate goal is to develop a single outpatient endoscopic procedure to treat obesity that does not require advanced endoscopic techniques and can be easily disseminated.
Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).

Background: Analysis from the Centres for Disease Control and Preventions (CMS) suggests the prevalence of obesity in the U.S. was 41.9% in 2017, and is expected to increase to 50% by 2030. Obesity is a major risk factor for multiple chronic diseases (such as type II diabetes and cardiovascular disease) and can lead to reduced quality of life as well as increased risk of death. Lifestyle modification (LM) has traditionally been a first-line treatment for adults with obesity but recent guidelines recommend bariatric intervention. Endoscopic sleeve gastroplasty (ESG) is a reversible, endoluminal organsparing bariatric procedure that has demonstrated sustained weight loss in people with obesity. The MERIT randomized, controlled trial (RCT) recently showed that ESG with concomitant LM (‘ESG’) led to significant and durable additional excess weight loss versus LM alone (‘LM’) among adults with class I (BMI 30.0-34.9 kg/m2) and class II obesity (BMI 35.0-39.9 kg/m2) as well as improvements in obesity-related comorbidities including type 2 diabetes.
Aim: We aimed to provide the first US cost-utility analysis of ESG vs LM among people with class II obesity.
Methods: The model was built from the perspective of the commercial US payor and methods were aligned with ISPOR recommendations. We used a 6-state Markov model that included 5 BMI-based health states and an additional absorbing death state (Figure 1). Clinical parameters were informed the MERIT Trial. Six-month cycles were used in the first year to reflect the significant and rapid weight loss observed with ESG and annual cycles were used thereafter. Estimates of utility for each health state, disutilities for adverse events, and the incidence of obesity-related comorbidities were based on published literature. One-way sensitivity and probabilistic sensitivity analyses were undertaken.
Results: ESG is highly cost-effective compared to LM from the US perspective. The base-case incremental cost-effectiveness ratio (ICER) for ESG vs LM was $9,281/QALY. The estimated incidence of diabetes had the largest impact on the ICER in one-way sensitivity analyses, though ESG was consistently cost effective across all sensitivity and dominant (cost-saving and improving quality of life) in scenario analyses with no upper bound ICER estimate exceeding $23,000/QALY gained, at a willingness to pay ratio of $50,000/QALY.
Conclusion: Compared with LM alone, ESG is a highly cost-effective treatment option for adults and should be used in selected patients requiring bariatric intervention from the US commercial perspective. Further clinical studies are required the cost effectiveness of ESG with other bariatric obesity interventions including LSG and pharmacological agents.
Cost Utility Model Structure

Cost Utility Model Structure

Background: The UK has one of the highest obesity rates in Europe affecting more than one-quarter of adults in England. Obesity is a risk factor for many chronic diseases and is associated with reduced quality of life and premature mortality. Lifestyle modification (LM) is the first-line treatment for obesity, but bariatric intervention is recommended in contemporary international guidelines for adults with class II obesity (body mass index [BMI] 35.0-39.9 kg/m2). Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure with robust evidence demonstrating its effectiveness and safety. The MERIT randomized controlled trial (RCT) showed that ESG with concomitant LM (‘ESG’) led to significant and durable additional excess weight loss versus LM alone (‘LM’) in adults with class I obesity (BMI 30.0-34.9 kg/m2) and class II obesity, as well as improvements in obesity-related comorbidities. This is the first cost-utility analysis comparing ESG with LM for adults with class II obesity, incorporating evidence from the MERIT RCT.
Methods: A 6-state Markov model was developed comprising 5 BMI-based health states and an absorbing death state (Figure 1). A UK healthcare payer perspective was adopted and methods were aligned with NICE guidance. Baseline characteristics, utilities, and transition probabilities were informed by patient-level data from the subset of patients with class II obesity in MERIT. Adverse events (AEs) were based on the MERIT safety population. Mortality was estimated by applying BMI-specific hazard ratios from the literature to UK general population mortality rates. Utilities for the healthy weight and overweight states were informed from the literature; disutility associated with increasing BMI in obesity I-III states was estimated using MERIT utility data. Disutilities due to AEs and the prevalence of obesity-related comorbidities were based on the literature. Costs included intervention costs, AE costs, and comorbidity costs.
Results: ESG resulted in higher overall costs than LM, but led to an increase in life years and quality-adjusted life years (QALYs) (Table 1). The incremental cost-effectiveness ratio (ICER) for ESG vs LM was £1,887/QALY gained. One-way sensitivity analysis showed that results were most sensitive to utility estimates, though ESG was consistently cost effective across all sensitivity analyses with no ICER estimate exceeding £4,000/QALY gained. In the probabilistic sensitivity analysis, ESG remained cost effective in 98.6% of iterations at a willingness-to-pay threshold of £20,000/QALY gained.
Conclusion: Our analysis suggests that compared with LM alone, ESG is a highly cost-effective treatment option for adults with class II obesity in the UK. Further research is needed to validate findings of this study and to compare the clinical and cost effectiveness of ESG with other bariatric obesity interventions.
Cost Utility Model Structure

Cost Utility Model Structure

Base Case Results

Base Case Results


Saturday
10:10am - 10:12am EDT - May 6, 2023 | Room: S502 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.
Background
Type 2 diabetes (T2D) affects 462 million people worldwide. Non-pharmacological interventions that can improve glycemic control in patients inadequately controlled with glucose-lowering medications (GLMs) have a potential to delay insulin initiation and modify disease progression. Duodenal mucosal regeneration (DMR) induced by thermal ablation has been associated with improved glycemic control in T2D patients.

Pulsed electric field (PEF) is a unique non-thermal modality that can selectively affect cells via electroporation. This first-in-human study evaluates the safety, feasibility and preliminary efficacy of endoscopic application of PEF to elicit DMR in T2D patients inadequately controlled on GLMs and is the first PEF application in gastrointestinal tract.

Method
This is an ongoing multicenter, open-label, treatment-only study. Key eligibility criteria are 18-70 years of age, history of T2D for ≤10 years, HbA1c of 7.5%-11.0%, BMI of 24 – 40 kg/m2, C-peptide ≥ 333 pmol/l, and on 1-4 non-insulin GLMs. The primary endpoint is the incidence of device- or procedure-related serious adverse events (SAEs) at 12 wks. Secondary endpoints include technical success and changes in glycemic control at 24 wks. The procedure is performed endoscopically using the ReCET™ device (Endogenex Inc.). Patients are followed for 48 wks, with endoscopic follow up at 4 wks. The GLMs are maintained stable for ≥12 wks before and ≥24 wks after the procedure.

Results
To date, 30 patients have been enrolled (Table 1). Technical success was 100%, with a mean treated length of 11.0 ± 1.9 cm, and median procedure time of 59 min (IQR 42 – 78). No device/procedure-related SAEs occurred. Forty-five device/procedure-related adverse events (AEs) were reported in 23/30 patients. Most reported AEs were sore throat (17/30) and transient diarrhea (9/30). AEs were mild (80%) or moderate (20%) in severity. At 4 wks, the treated areas showed complete healing, mostly unidentifiable endoscopically, with no signs of stricture, ulceration, or other significant findings.

The first 12 patients were treated with single energy application (single Tx). The subsequent 18 patients received double energy application (double Tx) and 14 have reached 24 wks. Clinically significant improvements in glycemic control were observed in these 14 patients. At 24 wks, mean HbA1c was 7.5% ± 1.1% vs. 8.4% ± 1.0% at baseline (p<0.01), FPG 7.5 ± 1.7 mmol/l vs. 9.8 ± 2.2 mmol/l (P<0.01), and HOMA-IR 4.5 ± 3.6 vs. 7.4 ± 3.3 (p<0.01). Weight loss was 5.1% ± 4.1% (p<0.01) at 24 wks. An energy dose-response relationship was observed between the single Tx and double Tx dose levels (P < 0.05) (Figure 1).

Conclusions
This first GI application of PEF in human demonstrated that the technology is feasible, safe, well tolerated by patients, and is associated with clinically meaningful improvement in glycemic control.
Background: Currently, there are several endoscopic procedures for the treatment of weight regain following Roux-en-Y gastric bypass (RYGB). These include argon plasma coagulation (APC), transoral outlet reduction via suturing (S-TORe) or plication (P-TORe). These procedures focus on reducing the size of the gastrojejunal anastomosis (GJA) and/or pouch. While their safety and efficacy have been established, there is no personalized approach to assist with procedure selection.

Aim: 1) To assess the efficacy of different endoscopic gastric bypass revision (EGBR) procedures 2) To construct an anatomy-based algorithm for the treatment of weight regain to optimize weight loss.

Methods: This is a single-center retrospective study of patients who underwent APC, S-TORe or P-TORe for the treatment of weight regain following RYGB. Patients who underwent EGBR using older suturing or plication platforms were excluded. Sensitivity analyses were performed to compare percent total weight loss (%TWL) at 12 months of different EGBR procedures at different GJA sizes. For pouch ≤ 5 cm, APC and S-TORe were compared as P-TORe is not typically performed given the length of the plication device. For pouch > 5 cm, S-TORe and P-TORe were compared as APC is not typically performed to reduce pouch volume. ANOVA was used for three group comparison and Student’s t-test for sensitivity analyses.

Results: 742 RYGB patients underwent 900 EGBR procedures. Of these, 191 (21%), 591 (66%) and 118 (13%) were APC, S-TORe and P-TORe, respectively. Baseline characteristics are shown in Table 1. At 12 months, patients in the APC, S-TORe and P-TORe experienced 8.1 ± 7.1 %TWL, 9.5 ± 8.7% TWL and 10.0 ± 8.5% TWL, respectively (p =0.25), with 70%, 72% and 63% experiencing at least 5% TWL (p = 0.50). There were no SAEs. Pouch ≤ 5 cm (APC vs S-TORe): On sensitivity analyses, with GJA < 18 mm, there was no difference in %TWL between APC and S-TORe (6.7 ± 7.7 %TWL vs 10.7 ± 11.1 %TWL, p=0.31). With GJA ≥ 18 mm, S-TORe yielded greater weight loss than APC (9.2 ± 8.2% TWL vs 5.3 ± 5.5% TWL, p=0.05). Pouch > 5 cm (S-TORe vs P-TORe): On sensitivity analyses, with GJA ≤ 25 mm, P-TORe yielded greater weight loss compared to S-TORe (13.2 ± 7.5%TWL vs 9.5 ± 9.1% TWL, p=0.04). With GJA > 25 mm, S-TORe yielded greater weight loss compared to P-TORe (17.1 ± 17.5% TWL vs -0.2 ± 7.5% TWL, p=0.03). Using results of the sensitivity analyses at different GJA size, an algorithm for the management of weight regain is constructed (Figure 1).

Conclusion: Endoscopic revision of RYGB in the treatment of weight regain can be individualized based on patient anatomy. For pouch ≤ 5 cm, S-TORe should be considered when GJA ≥ 18 mm, while either S-TORe or APC can be offered when GJA < 18 mm. For pouch > 5 cm, S-TORe should be considered when GJA > 25 mm, with P-TORe being offered when GJA ≤ 25 mm.
<b>Table 1</b>. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

Table 1. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

<b>Figure 1</b>. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Figure 1. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Introduction: Super-Obese patients presenting several comorbidities put foward a dilemma due to high perioperative adverse event rates. Although bariatric surgery remains to this moment the Gold standard of treatment while approaching those patients, not only as weight loss tools, but regarding their impact as metabolic procedures, only a small parcel accepts this option. Fear of complications even in then presence of extensive detailment opens a possibility for other solutions. Bariatric endoscopy proposes minimally invasive proceedings that can be an alternative not merely regarding weight loss but to the amelioration of comorbidities. Hence, it can postpone or even bypass surgery.
Objectives:
Methods: A cohort of 76 patients( mean age 43±7) with a BMI above 50 (51-63)was prospecticaly recruited and analysed retrospectively from February 2018 to January 2021. They were engaged to accomplish two consecutive endobariatric approaches. Firstly, a six-month nonadjustable intragastric balloon was placed, and at the time of the explant, an endoscopic sleeve Gastroplasty(Apollo Endosurgery) was executed.Weight loss results; Body mass composition (Inbody 720), elastography (Fibroscan, Echosens), HOMA-IR, Glicated Haemoglobin, Triglyceride levels, 24-Hour Ambulatory Blood Pressure Monitoring (ABPM), Sleep Apnea Disorders (polysommnography) were analysed by the student t test and the Wilcoxon test.
Results: 68 patients (55 females) completed the two consecutive procedures(3 early balloon removals; 2 not eligible for ESG at the time proposed and 3 opted for bariatric surgery )The average total body weight loss at IGB removal/ESG procedure was 19.74%(±4.67).ESG was accomplished with sucess on all, using an average of 5.6 sutures (4-7) with 15-22 bites per suture. One patient required hospitalization due to difficulty in extubation (2-day admission). No serious adverse event was reported. At 12 months, TBWL % was 32.57%.(+-9.79). 58 patients(75%), presented type 2 diabetes, and 88.2% had their medications decreased, with an average decrease in Hb1ac of 1.65%(+-1.22). Steatosis was present in 82% of patients (S2 score predominant;) and fibrosis in 21% of the group (F3 predominant).Improvements in 69.64 and 50 percent respectively(p<0.001) Sleep apnea in 69.11% with a betterment in 82.97%(p<0.001)ABPM melioration in all HBP bearers(p<0.001).
Conclusion: Although 18 Months were necessary to achieve those results, WL and betterment in comorbidities were similar to those reported after a surgical technique. The role of Endobariatrics broadens to other classes of patients rather than the predetermined originally to fill the gap between clinical and surgical approaches, targeting patients with a BMI of 30-40) and provides safe, effective and life-changing modifications.Therefore,could be offered as an alternative to those who can not or don not wish to undergo surgery.
Background and Aim: Current endoscopic bariatric therapies fail to achieve the same degree of weight loss and improvement in metabolic profile similar to laparoscopic sleeve gastrectomy (LSG) because they merely mimic its restrictive/anatomic aspects. Four essential requirements should be met to achieve the same anatomical and physiological benefits of surgery: (a) reducing gastric volume, (b) decreasing gastric compliance, (c) increasing gastric emptying, and (d) eradicating the hormonally active gastric mucosa. We aim to replicate the efficacy of LSG through a safe, simple, and effective endoscopic approach. We hypothesized that an endoscopic submucosal injection of a sclerosant agent can induce gastric remodeling that will mimic the effects of LSG.
Methods: To better simulate human physiology, we designed a 3D organ-on-a-chip (OoC) intestinal culture model to control cell
microenvironments and maintain tissue-specific functions. The OoC was constructed using co-culture of human intestinal epithelial cells (InEpC), human intestinal myofibroblasts (InMyoFib), and colon carcinoma cell line (Caco-2). The OoC was then treated with bleomycin (1, 1.5, and 2 ug/ml); minocycline (5,10, and 20 mg/ml); recombinant TGF-beta1 (10, 20, and 40 ng/ml), and negative control (Sodium Tetradecyl Sulfate;1000 uM). After initial cell viability testing, we performed immunostaining to detect the expression of fibrosis biomarkers: alpha-smooth muscle actin (alpha-SMA), and collagen-1 (Col-1). The examination was performed using high-resolution confocal microscopy
seven days after incubation.
Results: Bioprinted acellular tubes were constructed and cocultured with the selected cells successfully. The initial viability tests showed that most cells in the OoC culture survived the range of doses of the three candidate agents. However, there was a dose-dependent increase in the cell death ratio (Figure 1). Immunostaining showed that the three candidate agents induced a dose-dependent increase in the fibrotic reaction as evidenced by alpha-SMA actin and Col-1 expression compared to the control. The drug doses that produced the best outcome balance for cell death to the fibrotic reaction were 1.5 ug/ml for bleomycin, 10 mg/ml for minocycline, and 40 ng/ml for TGF-beta1 (Figure 2).
Conclusion: We successfully designed a 3D organ-on-a-chip intestinal culture model and induced an intense fibrotic reaction with bleomycin, minocycline, and recombinant TGF-beta1. This culture model represents a platform for future gastrointestinal research applications. We are currently leveraging our experience on this model to rodent and porcine animal models. The ultimate goal is to develop a single outpatient endoscopic procedure to treat obesity that does not require advanced endoscopic techniques and can be easily disseminated.
Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).

Background: Analysis from the Centres for Disease Control and Preventions (CMS) suggests the prevalence of obesity in the U.S. was 41.9% in 2017, and is expected to increase to 50% by 2030. Obesity is a major risk factor for multiple chronic diseases (such as type II diabetes and cardiovascular disease) and can lead to reduced quality of life as well as increased risk of death. Lifestyle modification (LM) has traditionally been a first-line treatment for adults with obesity but recent guidelines recommend bariatric intervention. Endoscopic sleeve gastroplasty (ESG) is a reversible, endoluminal organsparing bariatric procedure that has demonstrated sustained weight loss in people with obesity. The MERIT randomized, controlled trial (RCT) recently showed that ESG with concomitant LM (‘ESG’) led to significant and durable additional excess weight loss versus LM alone (‘LM’) among adults with class I (BMI 30.0-34.9 kg/m2) and class II obesity (BMI 35.0-39.9 kg/m2) as well as improvements in obesity-related comorbidities including type 2 diabetes.
Aim: We aimed to provide the first US cost-utility analysis of ESG vs LM among people with class II obesity.
Methods: The model was built from the perspective of the commercial US payor and methods were aligned with ISPOR recommendations. We used a 6-state Markov model that included 5 BMI-based health states and an additional absorbing death state (Figure 1). Clinical parameters were informed the MERIT Trial. Six-month cycles were used in the first year to reflect the significant and rapid weight loss observed with ESG and annual cycles were used thereafter. Estimates of utility for each health state, disutilities for adverse events, and the incidence of obesity-related comorbidities were based on published literature. One-way sensitivity and probabilistic sensitivity analyses were undertaken.
Results: ESG is highly cost-effective compared to LM from the US perspective. The base-case incremental cost-effectiveness ratio (ICER) for ESG vs LM was $9,281/QALY. The estimated incidence of diabetes had the largest impact on the ICER in one-way sensitivity analyses, though ESG was consistently cost effective across all sensitivity and dominant (cost-saving and improving quality of life) in scenario analyses with no upper bound ICER estimate exceeding $23,000/QALY gained, at a willingness to pay ratio of $50,000/QALY.
Conclusion: Compared with LM alone, ESG is a highly cost-effective treatment option for adults and should be used in selected patients requiring bariatric intervention from the US commercial perspective. Further clinical studies are required the cost effectiveness of ESG with other bariatric obesity interventions including LSG and pharmacological agents.
Cost Utility Model Structure

Cost Utility Model Structure

Background: The UK has one of the highest obesity rates in Europe affecting more than one-quarter of adults in England. Obesity is a risk factor for many chronic diseases and is associated with reduced quality of life and premature mortality. Lifestyle modification (LM) is the first-line treatment for obesity, but bariatric intervention is recommended in contemporary international guidelines for adults with class II obesity (body mass index [BMI] 35.0-39.9 kg/m2). Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure with robust evidence demonstrating its effectiveness and safety. The MERIT randomized controlled trial (RCT) showed that ESG with concomitant LM (‘ESG’) led to significant and durable additional excess weight loss versus LM alone (‘LM’) in adults with class I obesity (BMI 30.0-34.9 kg/m2) and class II obesity, as well as improvements in obesity-related comorbidities. This is the first cost-utility analysis comparing ESG with LM for adults with class II obesity, incorporating evidence from the MERIT RCT.
Methods: A 6-state Markov model was developed comprising 5 BMI-based health states and an absorbing death state (Figure 1). A UK healthcare payer perspective was adopted and methods were aligned with NICE guidance. Baseline characteristics, utilities, and transition probabilities were informed by patient-level data from the subset of patients with class II obesity in MERIT. Adverse events (AEs) were based on the MERIT safety population. Mortality was estimated by applying BMI-specific hazard ratios from the literature to UK general population mortality rates. Utilities for the healthy weight and overweight states were informed from the literature; disutility associated with increasing BMI in obesity I-III states was estimated using MERIT utility data. Disutilities due to AEs and the prevalence of obesity-related comorbidities were based on the literature. Costs included intervention costs, AE costs, and comorbidity costs.
Results: ESG resulted in higher overall costs than LM, but led to an increase in life years and quality-adjusted life years (QALYs) (Table 1). The incremental cost-effectiveness ratio (ICER) for ESG vs LM was £1,887/QALY gained. One-way sensitivity analysis showed that results were most sensitive to utility estimates, though ESG was consistently cost effective across all sensitivity analyses with no ICER estimate exceeding £4,000/QALY gained. In the probabilistic sensitivity analysis, ESG remained cost effective in 98.6% of iterations at a willingness-to-pay threshold of £20,000/QALY gained.
Conclusion: Our analysis suggests that compared with LM alone, ESG is a highly cost-effective treatment option for adults with class II obesity in the UK. Further research is needed to validate findings of this study and to compare the clinical and cost effectiveness of ESG with other bariatric obesity interventions.
Cost Utility Model Structure

Cost Utility Model Structure

Base Case Results

Base Case Results


Saturday
10:12am - 10:27am EDT - May 6, 2023 | Room: S502 (McCormick Place)
Barham Abu Dayyeh, Presenter
Society: ASGE
Type: Topic Forum
Society: ASGE

Background: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy (SG) and thought to result from progressive rotation and/or scarring of the sleeve. Objective diagnostic criteria for this condition are lacking. Given the increasing prevalence of SG procedures being performed and the rising incidence of GSS, the diagnosis of GSS is critical to expedite management and reduce patient suffering. Endoluminal impedance planimetry measurements including diameter and distensibility indices (DI) show promise in characterizing GSS, though normal and abnormal benchmark values have never been established.
Aims: To (1) establish benchmark values for the distribution of diameter and DI for normal gastric sleeve anatomy and across GSS severity, and (2) determine if impedance planimetry measurements can be used to characterize the severity of GSS.
Methods: This was a retrospective analysis of a prospective database of patients who underwent upper endoscopy with impedance planimetry for suspected GSS between 8/2018 and 11/2022. All upper endoscopies were performed by a single trained bariatric endoscopist who assessed the presence and severity of luminal narrowing and was blinded to impedance planimetry measurements. Endoscopist description of endoluminal narrowing was reported as normal [0], mild [1], moderate [2], or severe [3]. Impedance planimetry measurements were obtained by advancing the catheter across the GSS. Measurements were monitored for 60 seconds with 3 different balloon volumes (30ml, 40ml, and 50ml) and diameter and distensibility index (DI) were recorded. Primary outcome included luminal diameter and DI. Secondary outcomes included presence and severity of GSS on endoscopy.
Results: A total of 110 endoscopic procedures were included. No luminal narrowing was seen in 19 (17%). Luminal narrowing was graded as mild, moderate, and severe in 27 (25%), 34 (30%), and 30 (27%) of procedures, respectively. When stratified by severity, there was significant difference between impedance planimetry measurements of diameter and DI in all four categories using all 3 balloon volumes (Figure 1). In the group without luminal narrowing, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. Comparatively, in severe narrowing, mean (±SD) diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±7.1) to 7.7 (±4.3), respectively. Representative images of impedance planimetry for no luminal narrowing and mild, moderate, and severe stenosis are shown in Figure 2.
Conclusion: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. This study provides new benchmark values for the diagnosis and severity of GSS.
Background
Type 2 diabetes (T2D) affects 462 million people worldwide. Non-pharmacological interventions that can improve glycemic control in patients inadequately controlled with glucose-lowering medications (GLMs) have a potential to delay insulin initiation and modify disease progression. Duodenal mucosal regeneration (DMR) induced by thermal ablation has been associated with improved glycemic control in T2D patients.

Pulsed electric field (PEF) is a unique non-thermal modality that can selectively affect cells via electroporation. This first-in-human study evaluates the safety, feasibility and preliminary efficacy of endoscopic application of PEF to elicit DMR in T2D patients inadequately controlled on GLMs and is the first PEF application in gastrointestinal tract.

Method
This is an ongoing multicenter, open-label, treatment-only study. Key eligibility criteria are 18-70 years of age, history of T2D for ≤10 years, HbA1c of 7.5%-11.0%, BMI of 24 – 40 kg/m2, C-peptide ≥ 333 pmol/l, and on 1-4 non-insulin GLMs. The primary endpoint is the incidence of device- or procedure-related serious adverse events (SAEs) at 12 wks. Secondary endpoints include technical success and changes in glycemic control at 24 wks. The procedure is performed endoscopically using the ReCET™ device (Endogenex Inc.). Patients are followed for 48 wks, with endoscopic follow up at 4 wks. The GLMs are maintained stable for ≥12 wks before and ≥24 wks after the procedure.

Results
To date, 30 patients have been enrolled (Table 1). Technical success was 100%, with a mean treated length of 11.0 ± 1.9 cm, and median procedure time of 59 min (IQR 42 – 78). No device/procedure-related SAEs occurred. Forty-five device/procedure-related adverse events (AEs) were reported in 23/30 patients. Most reported AEs were sore throat (17/30) and transient diarrhea (9/30). AEs were mild (80%) or moderate (20%) in severity. At 4 wks, the treated areas showed complete healing, mostly unidentifiable endoscopically, with no signs of stricture, ulceration, or other significant findings.

The first 12 patients were treated with single energy application (single Tx). The subsequent 18 patients received double energy application (double Tx) and 14 have reached 24 wks. Clinically significant improvements in glycemic control were observed in these 14 patients. At 24 wks, mean HbA1c was 7.5% ± 1.1% vs. 8.4% ± 1.0% at baseline (p<0.01), FPG 7.5 ± 1.7 mmol/l vs. 9.8 ± 2.2 mmol/l (P<0.01), and HOMA-IR 4.5 ± 3.6 vs. 7.4 ± 3.3 (p<0.01). Weight loss was 5.1% ± 4.1% (p<0.01) at 24 wks. An energy dose-response relationship was observed between the single Tx and double Tx dose levels (P < 0.05) (Figure 1).

Conclusions
This first GI application of PEF in human demonstrated that the technology is feasible, safe, well tolerated by patients, and is associated with clinically meaningful improvement in glycemic control.
Background: Currently, there are several endoscopic procedures for the treatment of weight regain following Roux-en-Y gastric bypass (RYGB). These include argon plasma coagulation (APC), transoral outlet reduction via suturing (S-TORe) or plication (P-TORe). These procedures focus on reducing the size of the gastrojejunal anastomosis (GJA) and/or pouch. While their safety and efficacy have been established, there is no personalized approach to assist with procedure selection.

Aim: 1) To assess the efficacy of different endoscopic gastric bypass revision (EGBR) procedures 2) To construct an anatomy-based algorithm for the treatment of weight regain to optimize weight loss.

Methods: This is a single-center retrospective study of patients who underwent APC, S-TORe or P-TORe for the treatment of weight regain following RYGB. Patients who underwent EGBR using older suturing or plication platforms were excluded. Sensitivity analyses were performed to compare percent total weight loss (%TWL) at 12 months of different EGBR procedures at different GJA sizes. For pouch ≤ 5 cm, APC and S-TORe were compared as P-TORe is not typically performed given the length of the plication device. For pouch > 5 cm, S-TORe and P-TORe were compared as APC is not typically performed to reduce pouch volume. ANOVA was used for three group comparison and Student’s t-test for sensitivity analyses.

Results: 742 RYGB patients underwent 900 EGBR procedures. Of these, 191 (21%), 591 (66%) and 118 (13%) were APC, S-TORe and P-TORe, respectively. Baseline characteristics are shown in Table 1. At 12 months, patients in the APC, S-TORe and P-TORe experienced 8.1 ± 7.1 %TWL, 9.5 ± 8.7% TWL and 10.0 ± 8.5% TWL, respectively (p =0.25), with 70%, 72% and 63% experiencing at least 5% TWL (p = 0.50). There were no SAEs. Pouch ≤ 5 cm (APC vs S-TORe): On sensitivity analyses, with GJA < 18 mm, there was no difference in %TWL between APC and S-TORe (6.7 ± 7.7 %TWL vs 10.7 ± 11.1 %TWL, p=0.31). With GJA ≥ 18 mm, S-TORe yielded greater weight loss than APC (9.2 ± 8.2% TWL vs 5.3 ± 5.5% TWL, p=0.05). Pouch > 5 cm (S-TORe vs P-TORe): On sensitivity analyses, with GJA ≤ 25 mm, P-TORe yielded greater weight loss compared to S-TORe (13.2 ± 7.5%TWL vs 9.5 ± 9.1% TWL, p=0.04). With GJA > 25 mm, S-TORe yielded greater weight loss compared to P-TORe (17.1 ± 17.5% TWL vs -0.2 ± 7.5% TWL, p=0.03). Using results of the sensitivity analyses at different GJA size, an algorithm for the management of weight regain is constructed (Figure 1).

Conclusion: Endoscopic revision of RYGB in the treatment of weight regain can be individualized based on patient anatomy. For pouch ≤ 5 cm, S-TORe should be considered when GJA ≥ 18 mm, while either S-TORe or APC can be offered when GJA < 18 mm. For pouch > 5 cm, S-TORe should be considered when GJA > 25 mm, with P-TORe being offered when GJA ≤ 25 mm.
<b>Table 1</b>. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

Table 1. Baseline characteristics of RYGB patients with weight regain who underwent endoscopic gastric bypass revision (EGBR).

<b>Figure 1</b>. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Figure 1. An anatomy-based algorithm for the treatment of weight regain following Roux-en-Y gastric bypass. APC: argon plasma coagulation; S-TORe: suturing transoral outlet reduction; P-TORe: plication transoral outlet reduction; %TWL: percent total weight loss at 12 months. Bold font with * indicates statistical significance.

Introduction: Super-Obese patients presenting several comorbidities put foward a dilemma due to high perioperative adverse event rates. Although bariatric surgery remains to this moment the Gold standard of treatment while approaching those patients, not only as weight loss tools, but regarding their impact as metabolic procedures, only a small parcel accepts this option. Fear of complications even in then presence of extensive detailment opens a possibility for other solutions. Bariatric endoscopy proposes minimally invasive proceedings that can be an alternative not merely regarding weight loss but to the amelioration of comorbidities. Hence, it can postpone or even bypass surgery.
Objectives:
Methods: A cohort of 76 patients( mean age 43±7) with a BMI above 50 (51-63)was prospecticaly recruited and analysed retrospectively from February 2018 to January 2021. They were engaged to accomplish two consecutive endobariatric approaches. Firstly, a six-month nonadjustable intragastric balloon was placed, and at the time of the explant, an endoscopic sleeve Gastroplasty(Apollo Endosurgery) was executed.Weight loss results; Body mass composition (Inbody 720), elastography (Fibroscan, Echosens), HOMA-IR, Glicated Haemoglobin, Triglyceride levels, 24-Hour Ambulatory Blood Pressure Monitoring (ABPM), Sleep Apnea Disorders (polysommnography) were analysed by the student t test and the Wilcoxon test.
Results: 68 patients (55 females) completed the two consecutive procedures(3 early balloon removals; 2 not eligible for ESG at the time proposed and 3 opted for bariatric surgery )The average total body weight loss at IGB removal/ESG procedure was 19.74%(±4.67).ESG was accomplished with sucess on all, using an average of 5.6 sutures (4-7) with 15-22 bites per suture. One patient required hospitalization due to difficulty in extubation (2-day admission). No serious adverse event was reported. At 12 months, TBWL % was 32.57%.(+-9.79). 58 patients(75%), presented type 2 diabetes, and 88.2% had their medications decreased, with an average decrease in Hb1ac of 1.65%(+-1.22). Steatosis was present in 82% of patients (S2 score predominant;) and fibrosis in 21% of the group (F3 predominant).Improvements in 69.64 and 50 percent respectively(p<0.001) Sleep apnea in 69.11% with a betterment in 82.97%(p<0.001)ABPM melioration in all HBP bearers(p<0.001).
Conclusion: Although 18 Months were necessary to achieve those results, WL and betterment in comorbidities were similar to those reported after a surgical technique. The role of Endobariatrics broadens to other classes of patients rather than the predetermined originally to fill the gap between clinical and surgical approaches, targeting patients with a BMI of 30-40) and provides safe, effective and life-changing modifications.Therefore,could be offered as an alternative to those who can not or don not wish to undergo surgery.
Background and Aim: Current endoscopic bariatric therapies fail to achieve the same degree of weight loss and improvement in metabolic profile similar to laparoscopic sleeve gastrectomy (LSG) because they merely mimic its restrictive/anatomic aspects. Four essential requirements should be met to achieve the same anatomical and physiological benefits of surgery: (a) reducing gastric volume, (b) decreasing gastric compliance, (c) increasing gastric emptying, and (d) eradicating the hormonally active gastric mucosa. We aim to replicate the efficacy of LSG through a safe, simple, and effective endoscopic approach. We hypothesized that an endoscopic submucosal injection of a sclerosant agent can induce gastric remodeling that will mimic the effects of LSG.
Methods: To better simulate human physiology, we designed a 3D organ-on-a-chip (OoC) intestinal culture model to control cell
microenvironments and maintain tissue-specific functions. The OoC was constructed using co-culture of human intestinal epithelial cells (InEpC), human intestinal myofibroblasts (InMyoFib), and colon carcinoma cell line (Caco-2). The OoC was then treated with bleomycin (1, 1.5, and 2 ug/ml); minocycline (5,10, and 20 mg/ml); recombinant TGF-beta1 (10, 20, and 40 ng/ml), and negative control (Sodium Tetradecyl Sulfate;1000 uM). After initial cell viability testing, we performed immunostaining to detect the expression of fibrosis biomarkers: alpha-smooth muscle actin (alpha-SMA), and collagen-1 (Col-1). The examination was performed using high-resolution confocal microscopy
seven days after incubation.
Results: Bioprinted acellular tubes were constructed and cocultured with the selected cells successfully. The initial viability tests showed that most cells in the OoC culture survived the range of doses of the three candidate agents. However, there was a dose-dependent increase in the cell death ratio (Figure 1). Immunostaining showed that the three candidate agents induced a dose-dependent increase in the fibrotic reaction as evidenced by alpha-SMA actin and Col-1 expression compared to the control. The drug doses that produced the best outcome balance for cell death to the fibrotic reaction were 1.5 ug/ml for bleomycin, 10 mg/ml for minocycline, and 40 ng/ml for TGF-beta1 (Figure 2).
Conclusion: We successfully designed a 3D organ-on-a-chip intestinal culture model and induced an intense fibrotic reaction with bleomycin, minocycline, and recombinant TGF-beta1. This culture model represents a platform for future gastrointestinal research applications. We are currently leveraging our experience on this model to rodent and porcine animal models. The ultimate goal is to develop a single outpatient endoscopic procedure to treat obesity that does not require advanced endoscopic techniques and can be easily disseminated.
Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 1: a, b) brightfield microscopic images of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at day 4 after seeding CaCO2 cells; c) viability of co-cultured InMyoFibs+CaCO2 cells in the lumen of bioprinted tubes at Day 10 after seeding CaCO2 cells; d, e, f) microscopic images showing the viability of InMyoFibs+InEpCs +CaCO2 cells in the lumen bioprinted tubes at day 7 after addition of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively (note that the green color represents live cells, and the red represents dead cells); g, h, i) microscopic images showing immunostained for Collagen-I at Day 7 of 1.5 ug/ml bleomycin, 10 mg/ml for minocycline and 40 ng/ml TGF-beta1, respectively.

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).

Figure 2: Confocal images of the organ-on-a-chip culture showing immunostaining for α-SMA and Collagen-I (Col-I) at day 7 after the addition of 40 ng/ml recombinant TGFB1, and 1000 uM of Sodium Tetradecyl Sulfate (STS).

Background: Analysis from the Centres for Disease Control and Preventions (CMS) suggests the prevalence of obesity in the U.S. was 41.9% in 2017, and is expected to increase to 50% by 2030. Obesity is a major risk factor for multiple chronic diseases (such as type II diabetes and cardiovascular disease) and can lead to reduced quality of life as well as increased risk of death. Lifestyle modification (LM) has traditionally been a first-line treatment for adults with obesity but recent guidelines recommend bariatric intervention. Endoscopic sleeve gastroplasty (ESG) is a reversible, endoluminal organsparing bariatric procedure that has demonstrated sustained weight loss in people with obesity. The MERIT randomized, controlled trial (RCT) recently showed that ESG with concomitant LM (‘ESG’) led to significant and durable additional excess weight loss versus LM alone (‘LM’) among adults with class I (BMI 30.0-34.9 kg/m2) and class II obesity (BMI 35.0-39.9 kg/m2) as well as improvements in obesity-related comorbidities including type 2 diabetes.
Aim: We aimed to provide the first US cost-utility analysis of ESG vs LM among people with class II obesity.
Methods: The model was built from the perspective of the commercial US payor and methods were aligned with ISPOR recommendations. We used a 6-state Markov model that included 5 BMI-based health states and an additional absorbing death state (Figure 1). Clinical parameters were informed the MERIT Trial. Six-month cycles were used in the first year to reflect the significant and rapid weight loss observed with ESG and annual cycles were used thereafter. Estimates of utility for each health state, disutilities for adverse events, and the incidence of obesity-related comorbidities were based on published literature. One-way sensitivity and probabilistic sensitivity analyses were undertaken.
Results: ESG is highly cost-effective compared to LM from the US perspective. The base-case incremental cost-effectiveness ratio (ICER) for ESG vs LM was $9,281/QALY. The estimated incidence of diabetes had the largest impact on the ICER in one-way sensitivity analyses, though ESG was consistently cost effective across all sensitivity and dominant (cost-saving and improving quality of life) in scenario analyses with no upper bound ICER estimate exceeding $23,000/QALY gained, at a willingness to pay ratio of $50,000/QALY.
Conclusion: Compared with LM alone, ESG is a highly cost-effective treatment option for adults and should be used in selected patients requiring bariatric intervention from the US commercial perspective. Further clinical studies are required the cost effectiveness of ESG with other bariatric obesity interventions including LSG and pharmacological agents.
Cost Utility Model Structure

Cost Utility Model Structure

Background: The UK has one of the highest obesity rates in Europe affecting more than one-quarter of adults in England. Obesity is a risk factor for many chronic diseases and is associated with reduced quality of life and premature mortality. Lifestyle modification (LM) is the first-line treatment for obesity, but bariatric intervention is recommended in contemporary international guidelines for adults with class II obesity (body mass index [BMI] 35.0-39.9 kg/m2). Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure with robust evidence demonstrating its effectiveness and safety. The MERIT randomized controlled trial (RCT) showed that ESG with concomitant LM (‘ESG’) led to significant and durable additional excess weight loss versus LM alone (‘LM’) in adults with class I obesity (BMI 30.0-34.9 kg/m2) and class II obesity, as well as improvements in obesity-related comorbidities. This is the first cost-utility analysis comparing ESG with LM for adults with class II obesity, incorporating evidence from the MERIT RCT.
Methods: A 6-state Markov model was developed comprising 5 BMI-based health states and an absorbing death state (Figure 1). A UK healthcare payer perspective was adopted and methods were aligned with NICE guidance. Baseline characteristics, utilities, and transition probabilities were informed by patient-level data from the subset of patients with class II obesity in MERIT. Adverse events (AEs) were based on the MERIT safety population. Mortality was estimated by applying BMI-specific hazard ratios from the literature to UK general population mortality rates. Utilities for the healthy weight and overweight states were informed from the literature; disutility associated with increasing BMI in obesity I-III states was estimated using MERIT utility data. Disutilities due to AEs and the prevalence of obesity-related comorbidities were based on the literature. Costs included intervention costs, AE costs, and comorbidity costs.
Results: ESG resulted in higher overall costs than LM, but led to an increase in life years and quality-adjusted life years (QALYs) (Table 1). The incremental cost-effectiveness ratio (ICER) for ESG vs LM was £1,887/QALY gained. One-way sensitivity analysis showed that results were most sensitive to utility estimates, though ESG was consistently cost effective across all sensitivity analyses with no ICER estimate exceeding £4,000/QALY gained. In the probabilistic sensitivity analysis, ESG remained cost effective in 98.6% of iterations at a willingness-to-pay threshold of £20,000/QALY gained.
Conclusion: Our analysis suggests that compared with LM alone, ESG is a highly cost-effective treatment option for adults with class II obesity in the UK. Further research is needed to validate findings of this study and to compare the clinical and cost effectiveness of ESG with other bariatric obesity interventions.
Cost Utility Model Structure

Cost Utility Model Structure

Base Case Results

Base Case Results


09:00am - 10:30am EDT - May 6, 2023 | Room: S101 (McCormick Place)
Mohamed Othman, Moderator; Harish Gagneja, Moderator
Society: ASGE
Type: Topic Forum
Society: ASGE


Saturday
09:00am - 09:02am EDT - May 6, 2023 | Room: S101 (McCormick Place)
Mohamed Othman, Presenter; Harish Gagneja, Presenter
Society: ASGE
Type: Topic Forum
Society: ASGE


Saturday
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures


Saturday
09:10am - 09:12am EDT - May 6, 2023 | Room: S101 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures


Saturday
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.
<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.


Saturday
09:20am - 09:22am EDT - May 6, 2023 | Room: S101 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.
<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.


Saturday
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.
<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Background: Apart from adequate bowel preparation, colonic spasm is one of the significant problems that impair visualization during colonoscopy, and might affects the adenoma detection rate (ADR). When glucagon is not available, hyoscine was used to reduce colonic spasms with concerning adverse effects. In vitro research showed peppermint oil (PO) to be effective in relaxing colonic smooth muscle. Previous studies revealed the heterogeneous outcome of intraluminal PO on colonic spasms and ADR.
Aim: To investigate the efficacy of intraluminal PO on colonic peristalsis, ADR, polyp detection rate (PDR), adenoma per positive participants (APP), and safety.
Study design: A prospective, randomized, double-blinded, placebo-controlled trial was conducted. Of 408 patients, randomization to receive either a 50 ml solution of 1.6% PO plus simethicone (PO group) or simethicone alone (placebo group). All patients undergoing colonoscopy under propofol and/or fentanyl sedation supervised by an anesthesiologist. After the cecum was reached, the baseline colonic peristalsis score (0-3) was recorded. Then, the solution was infused through the scope channel over the cecum. The peristalsis score was graded again 30 seconds later and at the end of the procedure. An additional dose of solution or intravenous hyoscine can be requested if there is an inadequate response. Room air insufflation was used during scope withdrawal. Outcomes including ADR, APP, improvement of colonic peristalsis after spraying, procedure time, hemodynamic change, and patients’ symptoms after colonoscopy was assessed.
Results: The mean age was 60, and 67% were female. The patient’s characteristics were comparable among the two groups, and most of them achieved adequate bowel preparation (Table 1). Overall, ADR was 41.2%, and no difference was observed among the two groups (42.2% in PO vs. 40.2% in placebo, p=0.69). PDR (56.4% in PO vs. 55.9% in placebo, p=0.92) and APP (2.36 in PO vs. 2.21 in placebo, p= 0.23) were also no significant difference (Fig1a). The at least 1-grade improvement of peristalsis after the 1st spray was comparable between the two groups (Fig 1b). Interestingly, the overall mild or no peristalsis (score 0-1) was significantly higher in the placebo group (83.8% vs. 77.7%, p=0.006). Hyoscine was infrequently used, and no significant adverse events occurred in both group.
Conclusion: This randomized, double-blinded study failed to demonstrate the significant benefit of intraluminal PO in reducing colonic peristalsis or increasing ADR. However, overall peristalsis was gentle, and ADR was adequate. Further study to evaluate the appropriate dose and administration of PO is warranted.
Table 1. Patient’s characteristics and outcomes

Table 1. Patient’s characteristics and outcomes


Saturday
09:30am - 09:32am EDT - May 6, 2023 | Room: S101 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.
<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Background: Apart from adequate bowel preparation, colonic spasm is one of the significant problems that impair visualization during colonoscopy, and might affects the adenoma detection rate (ADR). When glucagon is not available, hyoscine was used to reduce colonic spasms with concerning adverse effects. In vitro research showed peppermint oil (PO) to be effective in relaxing colonic smooth muscle. Previous studies revealed the heterogeneous outcome of intraluminal PO on colonic spasms and ADR.
Aim: To investigate the efficacy of intraluminal PO on colonic peristalsis, ADR, polyp detection rate (PDR), adenoma per positive participants (APP), and safety.
Study design: A prospective, randomized, double-blinded, placebo-controlled trial was conducted. Of 408 patients, randomization to receive either a 50 ml solution of 1.6% PO plus simethicone (PO group) or simethicone alone (placebo group). All patients undergoing colonoscopy under propofol and/or fentanyl sedation supervised by an anesthesiologist. After the cecum was reached, the baseline colonic peristalsis score (0-3) was recorded. Then, the solution was infused through the scope channel over the cecum. The peristalsis score was graded again 30 seconds later and at the end of the procedure. An additional dose of solution or intravenous hyoscine can be requested if there is an inadequate response. Room air insufflation was used during scope withdrawal. Outcomes including ADR, APP, improvement of colonic peristalsis after spraying, procedure time, hemodynamic change, and patients’ symptoms after colonoscopy was assessed.
Results: The mean age was 60, and 67% were female. The patient’s characteristics were comparable among the two groups, and most of them achieved adequate bowel preparation (Table 1). Overall, ADR was 41.2%, and no difference was observed among the two groups (42.2% in PO vs. 40.2% in placebo, p=0.69). PDR (56.4% in PO vs. 55.9% in placebo, p=0.92) and APP (2.36 in PO vs. 2.21 in placebo, p= 0.23) were also no significant difference (Fig1a). The at least 1-grade improvement of peristalsis after the 1st spray was comparable between the two groups (Fig 1b). Interestingly, the overall mild or no peristalsis (score 0-1) was significantly higher in the placebo group (83.8% vs. 77.7%, p=0.006). Hyoscine was infrequently used, and no significant adverse events occurred in both group.
Conclusion: This randomized, double-blinded study failed to demonstrate the significant benefit of intraluminal PO in reducing colonic peristalsis or increasing ADR. However, overall peristalsis was gentle, and ADR was adequate. Further study to evaluate the appropriate dose and administration of PO is warranted.
Table 1. Patient’s characteristics and outcomes

Table 1. Patient’s characteristics and outcomes


Saturday
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.
<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Background: Apart from adequate bowel preparation, colonic spasm is one of the significant problems that impair visualization during colonoscopy, and might affects the adenoma detection rate (ADR). When glucagon is not available, hyoscine was used to reduce colonic spasms with concerning adverse effects. In vitro research showed peppermint oil (PO) to be effective in relaxing colonic smooth muscle. Previous studies revealed the heterogeneous outcome of intraluminal PO on colonic spasms and ADR.
Aim: To investigate the efficacy of intraluminal PO on colonic peristalsis, ADR, polyp detection rate (PDR), adenoma per positive participants (APP), and safety.
Study design: A prospective, randomized, double-blinded, placebo-controlled trial was conducted. Of 408 patients, randomization to receive either a 50 ml solution of 1.6% PO plus simethicone (PO group) or simethicone alone (placebo group). All patients undergoing colonoscopy under propofol and/or fentanyl sedation supervised by an anesthesiologist. After the cecum was reached, the baseline colonic peristalsis score (0-3) was recorded. Then, the solution was infused through the scope channel over the cecum. The peristalsis score was graded again 30 seconds later and at the end of the procedure. An additional dose of solution or intravenous hyoscine can be requested if there is an inadequate response. Room air insufflation was used during scope withdrawal. Outcomes including ADR, APP, improvement of colonic peristalsis after spraying, procedure time, hemodynamic change, and patients’ symptoms after colonoscopy was assessed.
Results: The mean age was 60, and 67% were female. The patient’s characteristics were comparable among the two groups, and most of them achieved adequate bowel preparation (Table 1). Overall, ADR was 41.2%, and no difference was observed among the two groups (42.2% in PO vs. 40.2% in placebo, p=0.69). PDR (56.4% in PO vs. 55.9% in placebo, p=0.92) and APP (2.36 in PO vs. 2.21 in placebo, p= 0.23) were also no significant difference (Fig1a). The at least 1-grade improvement of peristalsis after the 1st spray was comparable between the two groups (Fig 1b). Interestingly, the overall mild or no peristalsis (score 0-1) was significantly higher in the placebo group (83.8% vs. 77.7%, p=0.006). Hyoscine was infrequently used, and no significant adverse events occurred in both group.
Conclusion: This randomized, double-blinded study failed to demonstrate the significant benefit of intraluminal PO in reducing colonic peristalsis or increasing ADR. However, overall peristalsis was gentle, and ADR was adequate. Further study to evaluate the appropriate dose and administration of PO is warranted.
Table 1. Patient’s characteristics and outcomes

Table 1. Patient’s characteristics and outcomes

INTRODUCTION
Different virtual chromoendoscopy techniques to enhance imaging have shown controversial results in increasing Adenoma Detection Rate (ADR) during colonoscopy. A new imaging modality, Texture and Color Enhancing Imaging (TXI, Exera X1, Olympus, Japan) was recently proposed as a substitute to standard high definition white light (WLI) colonoscopy, but no study has assessed its efficacy in a clinical trial. We performed an international, multicenter randomized trial to assess the efficacy of TXI in detection of colorectal neoplasia.
METHODS
We enrolled consecutive patients >40 years old undergoing screening, surveillance or diagnostic colonoscopies at 5 centers (Italy, Germany, Japan) from September 2021 through May 2022. Patients were randomly assigned (1:1) to groups undergoing colonoscopies with TXI or WLI (controls). The primary outcome was adenoma detection rate (ADR, the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), and withdrawal time. Adjusted Odds Ratios (OR) for age, sex and colonoscopy indication were calculated.
RESULTS
We enrolled a total 747 patients, [11 expert endoscopists (mean age: 62.9±9.08 years)]. ADR was statistically significantly higher in the TXI group (221/375, 58.9%) than in the WLI group (159/372, 42.7%; adjusted RR: 1.35; 95% CI:1.17 to 1,56), as well as APC (1.36 ± 1.79 vs 0.89 ± 1.35; incident rate ratio, 1.53 [95% CI:1.25; 1.88]). No statistically significant difference in withdrawal time (TXI: 7.76±2.09 minutes vs WLI: 8.07 ±1.78; p = ns) was observed. No difference between TXI and control was observed in term of adequate (Boston Bowel Preparation Scale >2 in all colonic segments) cleansing (363/375, 96.8% vs 351/372, 94.4%) and cecal intubation rate (366/375 subjects, 97.6% vs 365/372, 98.1%).
CONCLUSIONS
In a multicenter randomized trial, we found that TXI increased ADR and APC in a non selected population of patients undergoing colonoscopy for various indications. TXI was associated with increased detection of polyps <10mm in size, both in the proximal and in the distal colon. The use of TXI during colonoscopy may be of benefit to increase colonoscopy quality indicators.

Saturday
09:40am - 09:42am EDT - May 6, 2023 | Room: S101 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.
<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Background: Apart from adequate bowel preparation, colonic spasm is one of the significant problems that impair visualization during colonoscopy, and might affects the adenoma detection rate (ADR). When glucagon is not available, hyoscine was used to reduce colonic spasms with concerning adverse effects. In vitro research showed peppermint oil (PO) to be effective in relaxing colonic smooth muscle. Previous studies revealed the heterogeneous outcome of intraluminal PO on colonic spasms and ADR.
Aim: To investigate the efficacy of intraluminal PO on colonic peristalsis, ADR, polyp detection rate (PDR), adenoma per positive participants (APP), and safety.
Study design: A prospective, randomized, double-blinded, placebo-controlled trial was conducted. Of 408 patients, randomization to receive either a 50 ml solution of 1.6% PO plus simethicone (PO group) or simethicone alone (placebo group). All patients undergoing colonoscopy under propofol and/or fentanyl sedation supervised by an anesthesiologist. After the cecum was reached, the baseline colonic peristalsis score (0-3) was recorded. Then, the solution was infused through the scope channel over the cecum. The peristalsis score was graded again 30 seconds later and at the end of the procedure. An additional dose of solution or intravenous hyoscine can be requested if there is an inadequate response. Room air insufflation was used during scope withdrawal. Outcomes including ADR, APP, improvement of colonic peristalsis after spraying, procedure time, hemodynamic change, and patients’ symptoms after colonoscopy was assessed.
Results: The mean age was 60, and 67% were female. The patient’s characteristics were comparable among the two groups, and most of them achieved adequate bowel preparation (Table 1). Overall, ADR was 41.2%, and no difference was observed among the two groups (42.2% in PO vs. 40.2% in placebo, p=0.69). PDR (56.4% in PO vs. 55.9% in placebo, p=0.92) and APP (2.36 in PO vs. 2.21 in placebo, p= 0.23) were also no significant difference (Fig1a). The at least 1-grade improvement of peristalsis after the 1st spray was comparable between the two groups (Fig 1b). Interestingly, the overall mild or no peristalsis (score 0-1) was significantly higher in the placebo group (83.8% vs. 77.7%, p=0.006). Hyoscine was infrequently used, and no significant adverse events occurred in both group.
Conclusion: This randomized, double-blinded study failed to demonstrate the significant benefit of intraluminal PO in reducing colonic peristalsis or increasing ADR. However, overall peristalsis was gentle, and ADR was adequate. Further study to evaluate the appropriate dose and administration of PO is warranted.
Table 1. Patient’s characteristics and outcomes

Table 1. Patient’s characteristics and outcomes

INTRODUCTION
Different virtual chromoendoscopy techniques to enhance imaging have shown controversial results in increasing Adenoma Detection Rate (ADR) during colonoscopy. A new imaging modality, Texture and Color Enhancing Imaging (TXI, Exera X1, Olympus, Japan) was recently proposed as a substitute to standard high definition white light (WLI) colonoscopy, but no study has assessed its efficacy in a clinical trial. We performed an international, multicenter randomized trial to assess the efficacy of TXI in detection of colorectal neoplasia.
METHODS
We enrolled consecutive patients >40 years old undergoing screening, surveillance or diagnostic colonoscopies at 5 centers (Italy, Germany, Japan) from September 2021 through May 2022. Patients were randomly assigned (1:1) to groups undergoing colonoscopies with TXI or WLI (controls). The primary outcome was adenoma detection rate (ADR, the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), and withdrawal time. Adjusted Odds Ratios (OR) for age, sex and colonoscopy indication were calculated.
RESULTS
We enrolled a total 747 patients, [11 expert endoscopists (mean age: 62.9±9.08 years)]. ADR was statistically significantly higher in the TXI group (221/375, 58.9%) than in the WLI group (159/372, 42.7%; adjusted RR: 1.35; 95% CI:1.17 to 1,56), as well as APC (1.36 ± 1.79 vs 0.89 ± 1.35; incident rate ratio, 1.53 [95% CI:1.25; 1.88]). No statistically significant difference in withdrawal time (TXI: 7.76±2.09 minutes vs WLI: 8.07 ±1.78; p = ns) was observed. No difference between TXI and control was observed in term of adequate (Boston Bowel Preparation Scale >2 in all colonic segments) cleansing (363/375, 96.8% vs 351/372, 94.4%) and cecal intubation rate (366/375 subjects, 97.6% vs 365/372, 98.1%).
CONCLUSIONS
In a multicenter randomized trial, we found that TXI increased ADR and APC in a non selected population of patients undergoing colonoscopy for various indications. TXI was associated with increased detection of polyps <10mm in size, both in the proximal and in the distal colon. The use of TXI during colonoscopy may be of benefit to increase colonoscopy quality indicators.

Saturday
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.
<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Background: Apart from adequate bowel preparation, colonic spasm is one of the significant problems that impair visualization during colonoscopy, and might affects the adenoma detection rate (ADR). When glucagon is not available, hyoscine was used to reduce colonic spasms with concerning adverse effects. In vitro research showed peppermint oil (PO) to be effective in relaxing colonic smooth muscle. Previous studies revealed the heterogeneous outcome of intraluminal PO on colonic spasms and ADR.
Aim: To investigate the efficacy of intraluminal PO on colonic peristalsis, ADR, polyp detection rate (PDR), adenoma per positive participants (APP), and safety.
Study design: A prospective, randomized, double-blinded, placebo-controlled trial was conducted. Of 408 patients, randomization to receive either a 50 ml solution of 1.6% PO plus simethicone (PO group) or simethicone alone (placebo group). All patients undergoing colonoscopy under propofol and/or fentanyl sedation supervised by an anesthesiologist. After the cecum was reached, the baseline colonic peristalsis score (0-3) was recorded. Then, the solution was infused through the scope channel over the cecum. The peristalsis score was graded again 30 seconds later and at the end of the procedure. An additional dose of solution or intravenous hyoscine can be requested if there is an inadequate response. Room air insufflation was used during scope withdrawal. Outcomes including ADR, APP, improvement of colonic peristalsis after spraying, procedure time, hemodynamic change, and patients’ symptoms after colonoscopy was assessed.
Results: The mean age was 60, and 67% were female. The patient’s characteristics were comparable among the two groups, and most of them achieved adequate bowel preparation (Table 1). Overall, ADR was 41.2%, and no difference was observed among the two groups (42.2% in PO vs. 40.2% in placebo, p=0.69). PDR (56.4% in PO vs. 55.9% in placebo, p=0.92) and APP (2.36 in PO vs. 2.21 in placebo, p= 0.23) were also no significant difference (Fig1a). The at least 1-grade improvement of peristalsis after the 1st spray was comparable between the two groups (Fig 1b). Interestingly, the overall mild or no peristalsis (score 0-1) was significantly higher in the placebo group (83.8% vs. 77.7%, p=0.006). Hyoscine was infrequently used, and no significant adverse events occurred in both group.
Conclusion: This randomized, double-blinded study failed to demonstrate the significant benefit of intraluminal PO in reducing colonic peristalsis or increasing ADR. However, overall peristalsis was gentle, and ADR was adequate. Further study to evaluate the appropriate dose and administration of PO is warranted.
Table 1. Patient’s characteristics and outcomes

Table 1. Patient’s characteristics and outcomes

INTRODUCTION
Different virtual chromoendoscopy techniques to enhance imaging have shown controversial results in increasing Adenoma Detection Rate (ADR) during colonoscopy. A new imaging modality, Texture and Color Enhancing Imaging (TXI, Exera X1, Olympus, Japan) was recently proposed as a substitute to standard high definition white light (WLI) colonoscopy, but no study has assessed its efficacy in a clinical trial. We performed an international, multicenter randomized trial to assess the efficacy of TXI in detection of colorectal neoplasia.
METHODS
We enrolled consecutive patients >40 years old undergoing screening, surveillance or diagnostic colonoscopies at 5 centers (Italy, Germany, Japan) from September 2021 through May 2022. Patients were randomly assigned (1:1) to groups undergoing colonoscopies with TXI or WLI (controls). The primary outcome was adenoma detection rate (ADR, the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), and withdrawal time. Adjusted Odds Ratios (OR) for age, sex and colonoscopy indication were calculated.
RESULTS
We enrolled a total 747 patients, [11 expert endoscopists (mean age: 62.9±9.08 years)]. ADR was statistically significantly higher in the TXI group (221/375, 58.9%) than in the WLI group (159/372, 42.7%; adjusted RR: 1.35; 95% CI:1.17 to 1,56), as well as APC (1.36 ± 1.79 vs 0.89 ± 1.35; incident rate ratio, 1.53 [95% CI:1.25; 1.88]). No statistically significant difference in withdrawal time (TXI: 7.76±2.09 minutes vs WLI: 8.07 ±1.78; p = ns) was observed. No difference between TXI and control was observed in term of adequate (Boston Bowel Preparation Scale >2 in all colonic segments) cleansing (363/375, 96.8% vs 351/372, 94.4%) and cecal intubation rate (366/375 subjects, 97.6% vs 365/372, 98.1%).
CONCLUSIONS
In a multicenter randomized trial, we found that TXI increased ADR and APC in a non selected population of patients undergoing colonoscopy for various indications. TXI was associated with increased detection of polyps <10mm in size, both in the proximal and in the distal colon. The use of TXI during colonoscopy may be of benefit to increase colonoscopy quality indicators.
Introduction
Endoscopic mucosal resection is an established treatment for adenomatous or early-stage cancers in the GI tract. However, the comparative effectiveness of EMR vs surgery in a real-world setting has not been fully established. We compared clinical outcomes & healthcare utilization between EMR vs surgery.
Methods
This was a retrospective cohort study of patients in a US-based health care organization. Patients 18-85yo were included if they had adenomas or early-stage cancer (T1N0) in the colon, esophagus, or stomach; had EMR or surgery from 1/1/08-12/31/17; & had ≥ 12 months of continuous membership post-intervention.
We compared the following clinical outcomes: polyp/lesion recurrence rate & 5-yr all-cause mortality of EMR vs surgery patients. We compared healthcare utilization outcomes: procedure vs operating time; initial hospital length of stay (LOS); & ER visits based on intervention. The EMR cohort was assembled from 3 advanced endoscopists’ data, each with >10 yrs of practice; the surgical cohort, from relevant CPT codes.
Lesion recurrence rate was found through keyword search of adenoma or carcinoma within 18mo of EMR or surgery & confirmed with chart review. Mortality data was identified from California Death Registry. Healthcare utilization data including 30-d ER visit was identified from electronic medical records. Patients were censored at death, plan disenrollment, up to 5-yrs post-intervention, or study completion. Time-to-event analysis was performed using Kaplan-Meier with Multivariable Cox proportional hazard analysis adjusted for age, gender, Charlson comorbidity, & smoking.
Results
There were 2728 patients (620 EMR, 2108 surgery); median age was 67 yrs, 50.4% were men, & majority were White (54.9%) & Hispanic (22.4%). 91.6% of EMR were colon (568/620); 4% esophagus (25/620); 4.4% stomach (27/620). 97.4% of surgeries were colon (2054/2108); 1% esophagus (21/2108); 1.6% stomach (33/2108). In the EMR cohort, 22 (3.5%) patients failed & required surgery.
18-mo recurrence was higher in the EMR group (10.8% vs 0%, p<0.0001), with most recurrences managed endoscopically (50/67, 74.6%). Both groups had similar 30-day procedure-related comorbidity (1% vs 2%, p=0.077), but EMR showed a survival advantage (EMR overall mortality with adjusted hazard ratio of 0.627 [95% CI 0.477-0.824, p < 0.0008] vs surgery). See figure 1.
EMR was faster than surgery [mean 41.8mins (SD 25mins) vs 130.6mins (SD 71.3mins); p<0.0001]. Initial LOS was shorter for the EMR cohort vs surgical cohort [mean 0 days (SD 0.3 days) vs 5.8 days (SD 6.2 days); p<0.0001]. Both groups had similar 30-day post-procedure ER visits (0.6% vs 1.5%, p = 0.0941).
Conclusion
1. Both EMR & surgery have high 30-day safety
2. Utilization metrics favor EMR over surgery
3. For adenomatous/early-stage cancers, there appears to be a survival advantage of EMR over surgery
Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.


Saturday
09:50am - 09:52am EDT - May 6, 2023 | Room: S101 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.
<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Background: Apart from adequate bowel preparation, colonic spasm is one of the significant problems that impair visualization during colonoscopy, and might affects the adenoma detection rate (ADR). When glucagon is not available, hyoscine was used to reduce colonic spasms with concerning adverse effects. In vitro research showed peppermint oil (PO) to be effective in relaxing colonic smooth muscle. Previous studies revealed the heterogeneous outcome of intraluminal PO on colonic spasms and ADR.
Aim: To investigate the efficacy of intraluminal PO on colonic peristalsis, ADR, polyp detection rate (PDR), adenoma per positive participants (APP), and safety.
Study design: A prospective, randomized, double-blinded, placebo-controlled trial was conducted. Of 408 patients, randomization to receive either a 50 ml solution of 1.6% PO plus simethicone (PO group) or simethicone alone (placebo group). All patients undergoing colonoscopy under propofol and/or fentanyl sedation supervised by an anesthesiologist. After the cecum was reached, the baseline colonic peristalsis score (0-3) was recorded. Then, the solution was infused through the scope channel over the cecum. The peristalsis score was graded again 30 seconds later and at the end of the procedure. An additional dose of solution or intravenous hyoscine can be requested if there is an inadequate response. Room air insufflation was used during scope withdrawal. Outcomes including ADR, APP, improvement of colonic peristalsis after spraying, procedure time, hemodynamic change, and patients’ symptoms after colonoscopy was assessed.
Results: The mean age was 60, and 67% were female. The patient’s characteristics were comparable among the two groups, and most of them achieved adequate bowel preparation (Table 1). Overall, ADR was 41.2%, and no difference was observed among the two groups (42.2% in PO vs. 40.2% in placebo, p=0.69). PDR (56.4% in PO vs. 55.9% in placebo, p=0.92) and APP (2.36 in PO vs. 2.21 in placebo, p= 0.23) were also no significant difference (Fig1a). The at least 1-grade improvement of peristalsis after the 1st spray was comparable between the two groups (Fig 1b). Interestingly, the overall mild or no peristalsis (score 0-1) was significantly higher in the placebo group (83.8% vs. 77.7%, p=0.006). Hyoscine was infrequently used, and no significant adverse events occurred in both group.
Conclusion: This randomized, double-blinded study failed to demonstrate the significant benefit of intraluminal PO in reducing colonic peristalsis or increasing ADR. However, overall peristalsis was gentle, and ADR was adequate. Further study to evaluate the appropriate dose and administration of PO is warranted.
Table 1. Patient’s characteristics and outcomes

Table 1. Patient’s characteristics and outcomes

INTRODUCTION
Different virtual chromoendoscopy techniques to enhance imaging have shown controversial results in increasing Adenoma Detection Rate (ADR) during colonoscopy. A new imaging modality, Texture and Color Enhancing Imaging (TXI, Exera X1, Olympus, Japan) was recently proposed as a substitute to standard high definition white light (WLI) colonoscopy, but no study has assessed its efficacy in a clinical trial. We performed an international, multicenter randomized trial to assess the efficacy of TXI in detection of colorectal neoplasia.
METHODS
We enrolled consecutive patients >40 years old undergoing screening, surveillance or diagnostic colonoscopies at 5 centers (Italy, Germany, Japan) from September 2021 through May 2022. Patients were randomly assigned (1:1) to groups undergoing colonoscopies with TXI or WLI (controls). The primary outcome was adenoma detection rate (ADR, the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), and withdrawal time. Adjusted Odds Ratios (OR) for age, sex and colonoscopy indication were calculated.
RESULTS
We enrolled a total 747 patients, [11 expert endoscopists (mean age: 62.9±9.08 years)]. ADR was statistically significantly higher in the TXI group (221/375, 58.9%) than in the WLI group (159/372, 42.7%; adjusted RR: 1.35; 95% CI:1.17 to 1,56), as well as APC (1.36 ± 1.79 vs 0.89 ± 1.35; incident rate ratio, 1.53 [95% CI:1.25; 1.88]). No statistically significant difference in withdrawal time (TXI: 7.76±2.09 minutes vs WLI: 8.07 ±1.78; p = ns) was observed. No difference between TXI and control was observed in term of adequate (Boston Bowel Preparation Scale >2 in all colonic segments) cleansing (363/375, 96.8% vs 351/372, 94.4%) and cecal intubation rate (366/375 subjects, 97.6% vs 365/372, 98.1%).
CONCLUSIONS
In a multicenter randomized trial, we found that TXI increased ADR and APC in a non selected population of patients undergoing colonoscopy for various indications. TXI was associated with increased detection of polyps <10mm in size, both in the proximal and in the distal colon. The use of TXI during colonoscopy may be of benefit to increase colonoscopy quality indicators.
Introduction
Endoscopic mucosal resection is an established treatment for adenomatous or early-stage cancers in the GI tract. However, the comparative effectiveness of EMR vs surgery in a real-world setting has not been fully established. We compared clinical outcomes & healthcare utilization between EMR vs surgery.
Methods
This was a retrospective cohort study of patients in a US-based health care organization. Patients 18-85yo were included if they had adenomas or early-stage cancer (T1N0) in the colon, esophagus, or stomach; had EMR or surgery from 1/1/08-12/31/17; & had ≥ 12 months of continuous membership post-intervention.
We compared the following clinical outcomes: polyp/lesion recurrence rate & 5-yr all-cause mortality of EMR vs surgery patients. We compared healthcare utilization outcomes: procedure vs operating time; initial hospital length of stay (LOS); & ER visits based on intervention. The EMR cohort was assembled from 3 advanced endoscopists’ data, each with >10 yrs of practice; the surgical cohort, from relevant CPT codes.
Lesion recurrence rate was found through keyword search of adenoma or carcinoma within 18mo of EMR or surgery & confirmed with chart review. Mortality data was identified from California Death Registry. Healthcare utilization data including 30-d ER visit was identified from electronic medical records. Patients were censored at death, plan disenrollment, up to 5-yrs post-intervention, or study completion. Time-to-event analysis was performed using Kaplan-Meier with Multivariable Cox proportional hazard analysis adjusted for age, gender, Charlson comorbidity, & smoking.
Results
There were 2728 patients (620 EMR, 2108 surgery); median age was 67 yrs, 50.4% were men, & majority were White (54.9%) & Hispanic (22.4%). 91.6% of EMR were colon (568/620); 4% esophagus (25/620); 4.4% stomach (27/620). 97.4% of surgeries were colon (2054/2108); 1% esophagus (21/2108); 1.6% stomach (33/2108). In the EMR cohort, 22 (3.5%) patients failed & required surgery.
18-mo recurrence was higher in the EMR group (10.8% vs 0%, p<0.0001), with most recurrences managed endoscopically (50/67, 74.6%). Both groups had similar 30-day procedure-related comorbidity (1% vs 2%, p=0.077), but EMR showed a survival advantage (EMR overall mortality with adjusted hazard ratio of 0.627 [95% CI 0.477-0.824, p < 0.0008] vs surgery). See figure 1.
EMR was faster than surgery [mean 41.8mins (SD 25mins) vs 130.6mins (SD 71.3mins); p<0.0001]. Initial LOS was shorter for the EMR cohort vs surgical cohort [mean 0 days (SD 0.3 days) vs 5.8 days (SD 6.2 days); p<0.0001]. Both groups had similar 30-day post-procedure ER visits (0.6% vs 1.5%, p = 0.0941).
Conclusion
1. Both EMR & surgery have high 30-day safety
2. Utilization metrics favor EMR over surgery
3. For adenomatous/early-stage cancers, there appears to be a survival advantage of EMR over surgery
Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.


Saturday
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.
<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Background: Apart from adequate bowel preparation, colonic spasm is one of the significant problems that impair visualization during colonoscopy, and might affects the adenoma detection rate (ADR). When glucagon is not available, hyoscine was used to reduce colonic spasms with concerning adverse effects. In vitro research showed peppermint oil (PO) to be effective in relaxing colonic smooth muscle. Previous studies revealed the heterogeneous outcome of intraluminal PO on colonic spasms and ADR.
Aim: To investigate the efficacy of intraluminal PO on colonic peristalsis, ADR, polyp detection rate (PDR), adenoma per positive participants (APP), and safety.
Study design: A prospective, randomized, double-blinded, placebo-controlled trial was conducted. Of 408 patients, randomization to receive either a 50 ml solution of 1.6% PO plus simethicone (PO group) or simethicone alone (placebo group). All patients undergoing colonoscopy under propofol and/or fentanyl sedation supervised by an anesthesiologist. After the cecum was reached, the baseline colonic peristalsis score (0-3) was recorded. Then, the solution was infused through the scope channel over the cecum. The peristalsis score was graded again 30 seconds later and at the end of the procedure. An additional dose of solution or intravenous hyoscine can be requested if there is an inadequate response. Room air insufflation was used during scope withdrawal. Outcomes including ADR, APP, improvement of colonic peristalsis after spraying, procedure time, hemodynamic change, and patients’ symptoms after colonoscopy was assessed.
Results: The mean age was 60, and 67% were female. The patient’s characteristics were comparable among the two groups, and most of them achieved adequate bowel preparation (Table 1). Overall, ADR was 41.2%, and no difference was observed among the two groups (42.2% in PO vs. 40.2% in placebo, p=0.69). PDR (56.4% in PO vs. 55.9% in placebo, p=0.92) and APP (2.36 in PO vs. 2.21 in placebo, p= 0.23) were also no significant difference (Fig1a). The at least 1-grade improvement of peristalsis after the 1st spray was comparable between the two groups (Fig 1b). Interestingly, the overall mild or no peristalsis (score 0-1) was significantly higher in the placebo group (83.8% vs. 77.7%, p=0.006). Hyoscine was infrequently used, and no significant adverse events occurred in both group.
Conclusion: This randomized, double-blinded study failed to demonstrate the significant benefit of intraluminal PO in reducing colonic peristalsis or increasing ADR. However, overall peristalsis was gentle, and ADR was adequate. Further study to evaluate the appropriate dose and administration of PO is warranted.
Table 1. Patient’s characteristics and outcomes

Table 1. Patient’s characteristics and outcomes

INTRODUCTION
Different virtual chromoendoscopy techniques to enhance imaging have shown controversial results in increasing Adenoma Detection Rate (ADR) during colonoscopy. A new imaging modality, Texture and Color Enhancing Imaging (TXI, Exera X1, Olympus, Japan) was recently proposed as a substitute to standard high definition white light (WLI) colonoscopy, but no study has assessed its efficacy in a clinical trial. We performed an international, multicenter randomized trial to assess the efficacy of TXI in detection of colorectal neoplasia.
METHODS
We enrolled consecutive patients >40 years old undergoing screening, surveillance or diagnostic colonoscopies at 5 centers (Italy, Germany, Japan) from September 2021 through May 2022. Patients were randomly assigned (1:1) to groups undergoing colonoscopies with TXI or WLI (controls). The primary outcome was adenoma detection rate (ADR, the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), and withdrawal time. Adjusted Odds Ratios (OR) for age, sex and colonoscopy indication were calculated.
RESULTS
We enrolled a total 747 patients, [11 expert endoscopists (mean age: 62.9±9.08 years)]. ADR was statistically significantly higher in the TXI group (221/375, 58.9%) than in the WLI group (159/372, 42.7%; adjusted RR: 1.35; 95% CI:1.17 to 1,56), as well as APC (1.36 ± 1.79 vs 0.89 ± 1.35; incident rate ratio, 1.53 [95% CI:1.25; 1.88]). No statistically significant difference in withdrawal time (TXI: 7.76±2.09 minutes vs WLI: 8.07 ±1.78; p = ns) was observed. No difference between TXI and control was observed in term of adequate (Boston Bowel Preparation Scale >2 in all colonic segments) cleansing (363/375, 96.8% vs 351/372, 94.4%) and cecal intubation rate (366/375 subjects, 97.6% vs 365/372, 98.1%).
CONCLUSIONS
In a multicenter randomized trial, we found that TXI increased ADR and APC in a non selected population of patients undergoing colonoscopy for various indications. TXI was associated with increased detection of polyps <10mm in size, both in the proximal and in the distal colon. The use of TXI during colonoscopy may be of benefit to increase colonoscopy quality indicators.
Introduction
Endoscopic mucosal resection is an established treatment for adenomatous or early-stage cancers in the GI tract. However, the comparative effectiveness of EMR vs surgery in a real-world setting has not been fully established. We compared clinical outcomes & healthcare utilization between EMR vs surgery.
Methods
This was a retrospective cohort study of patients in a US-based health care organization. Patients 18-85yo were included if they had adenomas or early-stage cancer (T1N0) in the colon, esophagus, or stomach; had EMR or surgery from 1/1/08-12/31/17; & had ≥ 12 months of continuous membership post-intervention.
We compared the following clinical outcomes: polyp/lesion recurrence rate & 5-yr all-cause mortality of EMR vs surgery patients. We compared healthcare utilization outcomes: procedure vs operating time; initial hospital length of stay (LOS); & ER visits based on intervention. The EMR cohort was assembled from 3 advanced endoscopists’ data, each with >10 yrs of practice; the surgical cohort, from relevant CPT codes.
Lesion recurrence rate was found through keyword search of adenoma or carcinoma within 18mo of EMR or surgery & confirmed with chart review. Mortality data was identified from California Death Registry. Healthcare utilization data including 30-d ER visit was identified from electronic medical records. Patients were censored at death, plan disenrollment, up to 5-yrs post-intervention, or study completion. Time-to-event analysis was performed using Kaplan-Meier with Multivariable Cox proportional hazard analysis adjusted for age, gender, Charlson comorbidity, & smoking.
Results
There were 2728 patients (620 EMR, 2108 surgery); median age was 67 yrs, 50.4% were men, & majority were White (54.9%) & Hispanic (22.4%). 91.6% of EMR were colon (568/620); 4% esophagus (25/620); 4.4% stomach (27/620). 97.4% of surgeries were colon (2054/2108); 1% esophagus (21/2108); 1.6% stomach (33/2108). In the EMR cohort, 22 (3.5%) patients failed & required surgery.
18-mo recurrence was higher in the EMR group (10.8% vs 0%, p<0.0001), with most recurrences managed endoscopically (50/67, 74.6%). Both groups had similar 30-day procedure-related comorbidity (1% vs 2%, p=0.077), but EMR showed a survival advantage (EMR overall mortality with adjusted hazard ratio of 0.627 [95% CI 0.477-0.824, p < 0.0008] vs surgery). See figure 1.
EMR was faster than surgery [mean 41.8mins (SD 25mins) vs 130.6mins (SD 71.3mins); p<0.0001]. Initial LOS was shorter for the EMR cohort vs surgical cohort [mean 0 days (SD 0.3 days) vs 5.8 days (SD 6.2 days); p<0.0001]. Both groups had similar 30-day post-procedure ER visits (0.6% vs 1.5%, p = 0.0941).
Conclusion
1. Both EMR & surgery have high 30-day safety
2. Utilization metrics favor EMR over surgery
3. For adenomatous/early-stage cancers, there appears to be a survival advantage of EMR over surgery
Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Background and Aim
Recently, advances have been made in image-enhanced endoscopy (IEE) technology and several methods that can be used in a clinical setting are available. Linked color imaging (LCI) is useful for surveillance endoscopy in high-risk patients; however, standard endoscopy is based on white light imaging (WLI) and IEE is not yet standard. Also, the superiority of narrow-band imaging (NBI), which was first developed, to WLI for detection of neoplastic lesions has not been clarified. The aim in this study was to verify the superiority of LCI to NBI for surveillance endoscopy using IEE.
Method
This study was conducted as an open-label, two-arm-parallel (1:1), multicenter, randomized controlled trial and registered in the Japan Registry of Clinical Trials (jRCT1012200006). Patients aged 20–85 years with a treatment history or with follow-up of epithelial tumors of the upper gastrointestinal tract who received surveillance endoscopy were recruited. Patients were assigned in a 1:1 ratio to an NBI group and an LCI group using a computerized minimization procedure. The endoscopy systems used were the LASEREO system (FUJIFILM Co., Tokyo, Japan) for LCI and the EVIS LUCERA ELITE system (Olympus Co., Tokyo, Japan) for NBI. According to randomization, endoscopic observation was performed with primary IEE followed by WLI (primary LCI and secondary WLI or primary NBI and secondary WLI). The primary endpoint was the detection rate of one or more epithelial neoplasms in the pharynx, esophagus and stomach, which was defined as the proportion of patients with tumors detected in the primary examination. The secondary endpoints included overlooked neoplastic lesions and procedure time.
Results
During the study period, a total of 372 patients in the NBI group and 378 patients in the LCI group in whom EGD was performed were analyzed. Neoplastic lesions were detected by NBI in 18 patients (4.6%) and were detected by LCI in 20 patients (5.3%) (P = 0.87). In secondary WLI, neoplastic lesions were detected in 11 patients in the NBI group (3.0%) and in 1 patient in the LCI group (0.27%) (P = 0.003). There was no significant difference between the two groups in the total number of neoplasms detected. Overlooked ratios were 36.7 % in primary NBI and 4.2% in primary LCI (P = 0.007). The mean observation times for primary IEE were 209.9 s in NBI and 215.3 s in LCI (P = 0.27).
Conclusions
LCI did not show superiority to NBI for detection of neoplastic lesions in high-risk patients. However, the percentage of overlooked lesions during primary NBI was significantly higher than that during primary LCI.

Saturday
10:00am - 10:02am EDT - May 6, 2023 | Room: S101 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.
<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Background: Apart from adequate bowel preparation, colonic spasm is one of the significant problems that impair visualization during colonoscopy, and might affects the adenoma detection rate (ADR). When glucagon is not available, hyoscine was used to reduce colonic spasms with concerning adverse effects. In vitro research showed peppermint oil (PO) to be effective in relaxing colonic smooth muscle. Previous studies revealed the heterogeneous outcome of intraluminal PO on colonic spasms and ADR.
Aim: To investigate the efficacy of intraluminal PO on colonic peristalsis, ADR, polyp detection rate (PDR), adenoma per positive participants (APP), and safety.
Study design: A prospective, randomized, double-blinded, placebo-controlled trial was conducted. Of 408 patients, randomization to receive either a 50 ml solution of 1.6% PO plus simethicone (PO group) or simethicone alone (placebo group). All patients undergoing colonoscopy under propofol and/or fentanyl sedation supervised by an anesthesiologist. After the cecum was reached, the baseline colonic peristalsis score (0-3) was recorded. Then, the solution was infused through the scope channel over the cecum. The peristalsis score was graded again 30 seconds later and at the end of the procedure. An additional dose of solution or intravenous hyoscine can be requested if there is an inadequate response. Room air insufflation was used during scope withdrawal. Outcomes including ADR, APP, improvement of colonic peristalsis after spraying, procedure time, hemodynamic change, and patients’ symptoms after colonoscopy was assessed.
Results: The mean age was 60, and 67% were female. The patient’s characteristics were comparable among the two groups, and most of them achieved adequate bowel preparation (Table 1). Overall, ADR was 41.2%, and no difference was observed among the two groups (42.2% in PO vs. 40.2% in placebo, p=0.69). PDR (56.4% in PO vs. 55.9% in placebo, p=0.92) and APP (2.36 in PO vs. 2.21 in placebo, p= 0.23) were also no significant difference (Fig1a). The at least 1-grade improvement of peristalsis after the 1st spray was comparable between the two groups (Fig 1b). Interestingly, the overall mild or no peristalsis (score 0-1) was significantly higher in the placebo group (83.8% vs. 77.7%, p=0.006). Hyoscine was infrequently used, and no significant adverse events occurred in both group.
Conclusion: This randomized, double-blinded study failed to demonstrate the significant benefit of intraluminal PO in reducing colonic peristalsis or increasing ADR. However, overall peristalsis was gentle, and ADR was adequate. Further study to evaluate the appropriate dose and administration of PO is warranted.
Table 1. Patient’s characteristics and outcomes

Table 1. Patient’s characteristics and outcomes

INTRODUCTION
Different virtual chromoendoscopy techniques to enhance imaging have shown controversial results in increasing Adenoma Detection Rate (ADR) during colonoscopy. A new imaging modality, Texture and Color Enhancing Imaging (TXI, Exera X1, Olympus, Japan) was recently proposed as a substitute to standard high definition white light (WLI) colonoscopy, but no study has assessed its efficacy in a clinical trial. We performed an international, multicenter randomized trial to assess the efficacy of TXI in detection of colorectal neoplasia.
METHODS
We enrolled consecutive patients >40 years old undergoing screening, surveillance or diagnostic colonoscopies at 5 centers (Italy, Germany, Japan) from September 2021 through May 2022. Patients were randomly assigned (1:1) to groups undergoing colonoscopies with TXI or WLI (controls). The primary outcome was adenoma detection rate (ADR, the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), and withdrawal time. Adjusted Odds Ratios (OR) for age, sex and colonoscopy indication were calculated.
RESULTS
We enrolled a total 747 patients, [11 expert endoscopists (mean age: 62.9±9.08 years)]. ADR was statistically significantly higher in the TXI group (221/375, 58.9%) than in the WLI group (159/372, 42.7%; adjusted RR: 1.35; 95% CI:1.17 to 1,56), as well as APC (1.36 ± 1.79 vs 0.89 ± 1.35; incident rate ratio, 1.53 [95% CI:1.25; 1.88]). No statistically significant difference in withdrawal time (TXI: 7.76±2.09 minutes vs WLI: 8.07 ±1.78; p = ns) was observed. No difference between TXI and control was observed in term of adequate (Boston Bowel Preparation Scale >2 in all colonic segments) cleansing (363/375, 96.8% vs 351/372, 94.4%) and cecal intubation rate (366/375 subjects, 97.6% vs 365/372, 98.1%).
CONCLUSIONS
In a multicenter randomized trial, we found that TXI increased ADR and APC in a non selected population of patients undergoing colonoscopy for various indications. TXI was associated with increased detection of polyps <10mm in size, both in the proximal and in the distal colon. The use of TXI during colonoscopy may be of benefit to increase colonoscopy quality indicators.
Introduction
Endoscopic mucosal resection is an established treatment for adenomatous or early-stage cancers in the GI tract. However, the comparative effectiveness of EMR vs surgery in a real-world setting has not been fully established. We compared clinical outcomes & healthcare utilization between EMR vs surgery.
Methods
This was a retrospective cohort study of patients in a US-based health care organization. Patients 18-85yo were included if they had adenomas or early-stage cancer (T1N0) in the colon, esophagus, or stomach; had EMR or surgery from 1/1/08-12/31/17; & had ≥ 12 months of continuous membership post-intervention.
We compared the following clinical outcomes: polyp/lesion recurrence rate & 5-yr all-cause mortality of EMR vs surgery patients. We compared healthcare utilization outcomes: procedure vs operating time; initial hospital length of stay (LOS); & ER visits based on intervention. The EMR cohort was assembled from 3 advanced endoscopists’ data, each with >10 yrs of practice; the surgical cohort, from relevant CPT codes.
Lesion recurrence rate was found through keyword search of adenoma or carcinoma within 18mo of EMR or surgery & confirmed with chart review. Mortality data was identified from California Death Registry. Healthcare utilization data including 30-d ER visit was identified from electronic medical records. Patients were censored at death, plan disenrollment, up to 5-yrs post-intervention, or study completion. Time-to-event analysis was performed using Kaplan-Meier with Multivariable Cox proportional hazard analysis adjusted for age, gender, Charlson comorbidity, & smoking.
Results
There were 2728 patients (620 EMR, 2108 surgery); median age was 67 yrs, 50.4% were men, & majority were White (54.9%) & Hispanic (22.4%). 91.6% of EMR were colon (568/620); 4% esophagus (25/620); 4.4% stomach (27/620). 97.4% of surgeries were colon (2054/2108); 1% esophagus (21/2108); 1.6% stomach (33/2108). In the EMR cohort, 22 (3.5%) patients failed & required surgery.
18-mo recurrence was higher in the EMR group (10.8% vs 0%, p<0.0001), with most recurrences managed endoscopically (50/67, 74.6%). Both groups had similar 30-day procedure-related comorbidity (1% vs 2%, p=0.077), but EMR showed a survival advantage (EMR overall mortality with adjusted hazard ratio of 0.627 [95% CI 0.477-0.824, p < 0.0008] vs surgery). See figure 1.
EMR was faster than surgery [mean 41.8mins (SD 25mins) vs 130.6mins (SD 71.3mins); p<0.0001]. Initial LOS was shorter for the EMR cohort vs surgical cohort [mean 0 days (SD 0.3 days) vs 5.8 days (SD 6.2 days); p<0.0001]. Both groups had similar 30-day post-procedure ER visits (0.6% vs 1.5%, p = 0.0941).
Conclusion
1. Both EMR & surgery have high 30-day safety
2. Utilization metrics favor EMR over surgery
3. For adenomatous/early-stage cancers, there appears to be a survival advantage of EMR over surgery
Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Background and Aim
Recently, advances have been made in image-enhanced endoscopy (IEE) technology and several methods that can be used in a clinical setting are available. Linked color imaging (LCI) is useful for surveillance endoscopy in high-risk patients; however, standard endoscopy is based on white light imaging (WLI) and IEE is not yet standard. Also, the superiority of narrow-band imaging (NBI), which was first developed, to WLI for detection of neoplastic lesions has not been clarified. The aim in this study was to verify the superiority of LCI to NBI for surveillance endoscopy using IEE.
Method
This study was conducted as an open-label, two-arm-parallel (1:1), multicenter, randomized controlled trial and registered in the Japan Registry of Clinical Trials (jRCT1012200006). Patients aged 20–85 years with a treatment history or with follow-up of epithelial tumors of the upper gastrointestinal tract who received surveillance endoscopy were recruited. Patients were assigned in a 1:1 ratio to an NBI group and an LCI group using a computerized minimization procedure. The endoscopy systems used were the LASEREO system (FUJIFILM Co., Tokyo, Japan) for LCI and the EVIS LUCERA ELITE system (Olympus Co., Tokyo, Japan) for NBI. According to randomization, endoscopic observation was performed with primary IEE followed by WLI (primary LCI and secondary WLI or primary NBI and secondary WLI). The primary endpoint was the detection rate of one or more epithelial neoplasms in the pharynx, esophagus and stomach, which was defined as the proportion of patients with tumors detected in the primary examination. The secondary endpoints included overlooked neoplastic lesions and procedure time.
Results
During the study period, a total of 372 patients in the NBI group and 378 patients in the LCI group in whom EGD was performed were analyzed. Neoplastic lesions were detected by NBI in 18 patients (4.6%) and were detected by LCI in 20 patients (5.3%) (P = 0.87). In secondary WLI, neoplastic lesions were detected in 11 patients in the NBI group (3.0%) and in 1 patient in the LCI group (0.27%) (P = 0.003). There was no significant difference between the two groups in the total number of neoplasms detected. Overlooked ratios were 36.7 % in primary NBI and 4.2% in primary LCI (P = 0.007). The mean observation times for primary IEE were 209.9 s in NBI and 215.3 s in LCI (P = 0.27).
Conclusions
LCI did not show superiority to NBI for detection of neoplastic lesions in high-risk patients. However, the percentage of overlooked lesions during primary NBI was significantly higher than that during primary LCI.

Saturday
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.
<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Background: Apart from adequate bowel preparation, colonic spasm is one of the significant problems that impair visualization during colonoscopy, and might affects the adenoma detection rate (ADR). When glucagon is not available, hyoscine was used to reduce colonic spasms with concerning adverse effects. In vitro research showed peppermint oil (PO) to be effective in relaxing colonic smooth muscle. Previous studies revealed the heterogeneous outcome of intraluminal PO on colonic spasms and ADR.
Aim: To investigate the efficacy of intraluminal PO on colonic peristalsis, ADR, polyp detection rate (PDR), adenoma per positive participants (APP), and safety.
Study design: A prospective, randomized, double-blinded, placebo-controlled trial was conducted. Of 408 patients, randomization to receive either a 50 ml solution of 1.6% PO plus simethicone (PO group) or simethicone alone (placebo group). All patients undergoing colonoscopy under propofol and/or fentanyl sedation supervised by an anesthesiologist. After the cecum was reached, the baseline colonic peristalsis score (0-3) was recorded. Then, the solution was infused through the scope channel over the cecum. The peristalsis score was graded again 30 seconds later and at the end of the procedure. An additional dose of solution or intravenous hyoscine can be requested if there is an inadequate response. Room air insufflation was used during scope withdrawal. Outcomes including ADR, APP, improvement of colonic peristalsis after spraying, procedure time, hemodynamic change, and patients’ symptoms after colonoscopy was assessed.
Results: The mean age was 60, and 67% were female. The patient’s characteristics were comparable among the two groups, and most of them achieved adequate bowel preparation (Table 1). Overall, ADR was 41.2%, and no difference was observed among the two groups (42.2% in PO vs. 40.2% in placebo, p=0.69). PDR (56.4% in PO vs. 55.9% in placebo, p=0.92) and APP (2.36 in PO vs. 2.21 in placebo, p= 0.23) were also no significant difference (Fig1a). The at least 1-grade improvement of peristalsis after the 1st spray was comparable between the two groups (Fig 1b). Interestingly, the overall mild or no peristalsis (score 0-1) was significantly higher in the placebo group (83.8% vs. 77.7%, p=0.006). Hyoscine was infrequently used, and no significant adverse events occurred in both group.
Conclusion: This randomized, double-blinded study failed to demonstrate the significant benefit of intraluminal PO in reducing colonic peristalsis or increasing ADR. However, overall peristalsis was gentle, and ADR was adequate. Further study to evaluate the appropriate dose and administration of PO is warranted.
Table 1. Patient’s characteristics and outcomes

Table 1. Patient’s characteristics and outcomes

INTRODUCTION
Different virtual chromoendoscopy techniques to enhance imaging have shown controversial results in increasing Adenoma Detection Rate (ADR) during colonoscopy. A new imaging modality, Texture and Color Enhancing Imaging (TXI, Exera X1, Olympus, Japan) was recently proposed as a substitute to standard high definition white light (WLI) colonoscopy, but no study has assessed its efficacy in a clinical trial. We performed an international, multicenter randomized trial to assess the efficacy of TXI in detection of colorectal neoplasia.
METHODS
We enrolled consecutive patients >40 years old undergoing screening, surveillance or diagnostic colonoscopies at 5 centers (Italy, Germany, Japan) from September 2021 through May 2022. Patients were randomly assigned (1:1) to groups undergoing colonoscopies with TXI or WLI (controls). The primary outcome was adenoma detection rate (ADR, the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), and withdrawal time. Adjusted Odds Ratios (OR) for age, sex and colonoscopy indication were calculated.
RESULTS
We enrolled a total 747 patients, [11 expert endoscopists (mean age: 62.9±9.08 years)]. ADR was statistically significantly higher in the TXI group (221/375, 58.9%) than in the WLI group (159/372, 42.7%; adjusted RR: 1.35; 95% CI:1.17 to 1,56), as well as APC (1.36 ± 1.79 vs 0.89 ± 1.35; incident rate ratio, 1.53 [95% CI:1.25; 1.88]). No statistically significant difference in withdrawal time (TXI: 7.76±2.09 minutes vs WLI: 8.07 ±1.78; p = ns) was observed. No difference between TXI and control was observed in term of adequate (Boston Bowel Preparation Scale >2 in all colonic segments) cleansing (363/375, 96.8% vs 351/372, 94.4%) and cecal intubation rate (366/375 subjects, 97.6% vs 365/372, 98.1%).
CONCLUSIONS
In a multicenter randomized trial, we found that TXI increased ADR and APC in a non selected population of patients undergoing colonoscopy for various indications. TXI was associated with increased detection of polyps <10mm in size, both in the proximal and in the distal colon. The use of TXI during colonoscopy may be of benefit to increase colonoscopy quality indicators.
Introduction
Endoscopic mucosal resection is an established treatment for adenomatous or early-stage cancers in the GI tract. However, the comparative effectiveness of EMR vs surgery in a real-world setting has not been fully established. We compared clinical outcomes & healthcare utilization between EMR vs surgery.
Methods
This was a retrospective cohort study of patients in a US-based health care organization. Patients 18-85yo were included if they had adenomas or early-stage cancer (T1N0) in the colon, esophagus, or stomach; had EMR or surgery from 1/1/08-12/31/17; & had ≥ 12 months of continuous membership post-intervention.
We compared the following clinical outcomes: polyp/lesion recurrence rate & 5-yr all-cause mortality of EMR vs surgery patients. We compared healthcare utilization outcomes: procedure vs operating time; initial hospital length of stay (LOS); & ER visits based on intervention. The EMR cohort was assembled from 3 advanced endoscopists’ data, each with >10 yrs of practice; the surgical cohort, from relevant CPT codes.
Lesion recurrence rate was found through keyword search of adenoma or carcinoma within 18mo of EMR or surgery & confirmed with chart review. Mortality data was identified from California Death Registry. Healthcare utilization data including 30-d ER visit was identified from electronic medical records. Patients were censored at death, plan disenrollment, up to 5-yrs post-intervention, or study completion. Time-to-event analysis was performed using Kaplan-Meier with Multivariable Cox proportional hazard analysis adjusted for age, gender, Charlson comorbidity, & smoking.
Results
There were 2728 patients (620 EMR, 2108 surgery); median age was 67 yrs, 50.4% were men, & majority were White (54.9%) & Hispanic (22.4%). 91.6% of EMR were colon (568/620); 4% esophagus (25/620); 4.4% stomach (27/620). 97.4% of surgeries were colon (2054/2108); 1% esophagus (21/2108); 1.6% stomach (33/2108). In the EMR cohort, 22 (3.5%) patients failed & required surgery.
18-mo recurrence was higher in the EMR group (10.8% vs 0%, p<0.0001), with most recurrences managed endoscopically (50/67, 74.6%). Both groups had similar 30-day procedure-related comorbidity (1% vs 2%, p=0.077), but EMR showed a survival advantage (EMR overall mortality with adjusted hazard ratio of 0.627 [95% CI 0.477-0.824, p < 0.0008] vs surgery). See figure 1.
EMR was faster than surgery [mean 41.8mins (SD 25mins) vs 130.6mins (SD 71.3mins); p<0.0001]. Initial LOS was shorter for the EMR cohort vs surgical cohort [mean 0 days (SD 0.3 days) vs 5.8 days (SD 6.2 days); p<0.0001]. Both groups had similar 30-day post-procedure ER visits (0.6% vs 1.5%, p = 0.0941).
Conclusion
1. Both EMR & surgery have high 30-day safety
2. Utilization metrics favor EMR over surgery
3. For adenomatous/early-stage cancers, there appears to be a survival advantage of EMR over surgery
Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Background and Aim
Recently, advances have been made in image-enhanced endoscopy (IEE) technology and several methods that can be used in a clinical setting are available. Linked color imaging (LCI) is useful for surveillance endoscopy in high-risk patients; however, standard endoscopy is based on white light imaging (WLI) and IEE is not yet standard. Also, the superiority of narrow-band imaging (NBI), which was first developed, to WLI for detection of neoplastic lesions has not been clarified. The aim in this study was to verify the superiority of LCI to NBI for surveillance endoscopy using IEE.
Method
This study was conducted as an open-label, two-arm-parallel (1:1), multicenter, randomized controlled trial and registered in the Japan Registry of Clinical Trials (jRCT1012200006). Patients aged 20–85 years with a treatment history or with follow-up of epithelial tumors of the upper gastrointestinal tract who received surveillance endoscopy were recruited. Patients were assigned in a 1:1 ratio to an NBI group and an LCI group using a computerized minimization procedure. The endoscopy systems used were the LASEREO system (FUJIFILM Co., Tokyo, Japan) for LCI and the EVIS LUCERA ELITE system (Olympus Co., Tokyo, Japan) for NBI. According to randomization, endoscopic observation was performed with primary IEE followed by WLI (primary LCI and secondary WLI or primary NBI and secondary WLI). The primary endpoint was the detection rate of one or more epithelial neoplasms in the pharynx, esophagus and stomach, which was defined as the proportion of patients with tumors detected in the primary examination. The secondary endpoints included overlooked neoplastic lesions and procedure time.
Results
During the study period, a total of 372 patients in the NBI group and 378 patients in the LCI group in whom EGD was performed were analyzed. Neoplastic lesions were detected by NBI in 18 patients (4.6%) and were detected by LCI in 20 patients (5.3%) (P = 0.87). In secondary WLI, neoplastic lesions were detected in 11 patients in the NBI group (3.0%) and in 1 patient in the LCI group (0.27%) (P = 0.003). There was no significant difference between the two groups in the total number of neoplasms detected. Overlooked ratios were 36.7 % in primary NBI and 4.2% in primary LCI (P = 0.007). The mean observation times for primary IEE were 209.9 s in NBI and 215.3 s in LCI (P = 0.27).
Conclusions
LCI did not show superiority to NBI for detection of neoplastic lesions in high-risk patients. However, the percentage of overlooked lesions during primary NBI was significantly higher than that during primary LCI.
Background and study aim
Endoscopic ultrasound guided through-the-needle biopsy (EUS-TTNB) has improved the diagnostic algorithm of pancreatic cystic neoplasms (PCN). However, the fragments obtained are very small and sometimes not eye-visible with the risk of loss during the preparation process.
Fluorescence Confocal Laser Microscopy (FCM) allows imaging of tissues in the fresh state, requiring minimal preparation without damage or loss of tissue.
The primary aim of this study was to assess the feasibility of the FCM with MAVIG VivaScope® 2500M-G4 microscope on the fragment obtained from EUS TTNB. The secondary aim was to assess the concordance between the diagnosis with VivaScope® and the standard technique.
Methods
Single centre prospective study conducted on consecutive patients with PCN who underwent EUS-TTNB at the Endoscopy Unit of Campus Bio-Medico University hospital. A 19 G needle with pre-loaded micro-forcep was used in all cases. Obtained samples were placed directly in a dedicated scaffold (Cytomatrix, UCS Diagnostics) and evaluated at FCM and classified as “Inadequate” or “Adequate”. Adequate samples were classified as serous, mucinous or other on the sole basis of the morphological characteristics of the epithelial lining.
Results
From June 2021 to September 2022, 15 patients were enrolled.
Seven (47%) PCNs were located in the body of the pancreas, while 5 (33.3%) in the head and 3 (22%) in the tail. The mean size of PCNs was 39.2±8.8 mm.
At VivaScope® evaluation, the sample was defined adequate in 14/15 (93.3%).
Among the adequate samples, 10/14 (71.4%) was defined mucinous, 2/14 (14.3%) serous cystoadenoma, 1/14 (7.1%) pseudocyst and 1 (7.1%) neuroendocrine cystic tumour.
There was a good agreement between the VivaScope® diagnosis and the final histological diagnosis (kappa Cohen’s coefficient 1, p = 0.001).
When evaluating VivaScope®’s diagnostic performances the Sensitivity was 100%, 95% CI 76.8%-100%, the Specificity 100%, 95% CI 2.5%-100%, PPV 100%, NPV 100% and Accuracy 100% 95% CI 78.2-100%.
Conclusion
FCM represents a new technique successfully applicable to micro-histological specimens. It provides fast information about sample adequacy and diagnosis in small specimens with good agreement with the final histology. However, a larger sample is necessary to confirm these data.

Saturday
10:10am - 10:12am EDT - May 6, 2023 | Room: S101 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.
<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Background: Apart from adequate bowel preparation, colonic spasm is one of the significant problems that impair visualization during colonoscopy, and might affects the adenoma detection rate (ADR). When glucagon is not available, hyoscine was used to reduce colonic spasms with concerning adverse effects. In vitro research showed peppermint oil (PO) to be effective in relaxing colonic smooth muscle. Previous studies revealed the heterogeneous outcome of intraluminal PO on colonic spasms and ADR.
Aim: To investigate the efficacy of intraluminal PO on colonic peristalsis, ADR, polyp detection rate (PDR), adenoma per positive participants (APP), and safety.
Study design: A prospective, randomized, double-blinded, placebo-controlled trial was conducted. Of 408 patients, randomization to receive either a 50 ml solution of 1.6% PO plus simethicone (PO group) or simethicone alone (placebo group). All patients undergoing colonoscopy under propofol and/or fentanyl sedation supervised by an anesthesiologist. After the cecum was reached, the baseline colonic peristalsis score (0-3) was recorded. Then, the solution was infused through the scope channel over the cecum. The peristalsis score was graded again 30 seconds later and at the end of the procedure. An additional dose of solution or intravenous hyoscine can be requested if there is an inadequate response. Room air insufflation was used during scope withdrawal. Outcomes including ADR, APP, improvement of colonic peristalsis after spraying, procedure time, hemodynamic change, and patients’ symptoms after colonoscopy was assessed.
Results: The mean age was 60, and 67% were female. The patient’s characteristics were comparable among the two groups, and most of them achieved adequate bowel preparation (Table 1). Overall, ADR was 41.2%, and no difference was observed among the two groups (42.2% in PO vs. 40.2% in placebo, p=0.69). PDR (56.4% in PO vs. 55.9% in placebo, p=0.92) and APP (2.36 in PO vs. 2.21 in placebo, p= 0.23) were also no significant difference (Fig1a). The at least 1-grade improvement of peristalsis after the 1st spray was comparable between the two groups (Fig 1b). Interestingly, the overall mild or no peristalsis (score 0-1) was significantly higher in the placebo group (83.8% vs. 77.7%, p=0.006). Hyoscine was infrequently used, and no significant adverse events occurred in both group.
Conclusion: This randomized, double-blinded study failed to demonstrate the significant benefit of intraluminal PO in reducing colonic peristalsis or increasing ADR. However, overall peristalsis was gentle, and ADR was adequate. Further study to evaluate the appropriate dose and administration of PO is warranted.
Table 1. Patient’s characteristics and outcomes

Table 1. Patient’s characteristics and outcomes

INTRODUCTION
Different virtual chromoendoscopy techniques to enhance imaging have shown controversial results in increasing Adenoma Detection Rate (ADR) during colonoscopy. A new imaging modality, Texture and Color Enhancing Imaging (TXI, Exera X1, Olympus, Japan) was recently proposed as a substitute to standard high definition white light (WLI) colonoscopy, but no study has assessed its efficacy in a clinical trial. We performed an international, multicenter randomized trial to assess the efficacy of TXI in detection of colorectal neoplasia.
METHODS
We enrolled consecutive patients >40 years old undergoing screening, surveillance or diagnostic colonoscopies at 5 centers (Italy, Germany, Japan) from September 2021 through May 2022. Patients were randomly assigned (1:1) to groups undergoing colonoscopies with TXI or WLI (controls). The primary outcome was adenoma detection rate (ADR, the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), and withdrawal time. Adjusted Odds Ratios (OR) for age, sex and colonoscopy indication were calculated.
RESULTS
We enrolled a total 747 patients, [11 expert endoscopists (mean age: 62.9±9.08 years)]. ADR was statistically significantly higher in the TXI group (221/375, 58.9%) than in the WLI group (159/372, 42.7%; adjusted RR: 1.35; 95% CI:1.17 to 1,56), as well as APC (1.36 ± 1.79 vs 0.89 ± 1.35; incident rate ratio, 1.53 [95% CI:1.25; 1.88]). No statistically significant difference in withdrawal time (TXI: 7.76±2.09 minutes vs WLI: 8.07 ±1.78; p = ns) was observed. No difference between TXI and control was observed in term of adequate (Boston Bowel Preparation Scale >2 in all colonic segments) cleansing (363/375, 96.8% vs 351/372, 94.4%) and cecal intubation rate (366/375 subjects, 97.6% vs 365/372, 98.1%).
CONCLUSIONS
In a multicenter randomized trial, we found that TXI increased ADR and APC in a non selected population of patients undergoing colonoscopy for various indications. TXI was associated with increased detection of polyps <10mm in size, both in the proximal and in the distal colon. The use of TXI during colonoscopy may be of benefit to increase colonoscopy quality indicators.
Introduction
Endoscopic mucosal resection is an established treatment for adenomatous or early-stage cancers in the GI tract. However, the comparative effectiveness of EMR vs surgery in a real-world setting has not been fully established. We compared clinical outcomes & healthcare utilization between EMR vs surgery.
Methods
This was a retrospective cohort study of patients in a US-based health care organization. Patients 18-85yo were included if they had adenomas or early-stage cancer (T1N0) in the colon, esophagus, or stomach; had EMR or surgery from 1/1/08-12/31/17; & had ≥ 12 months of continuous membership post-intervention.
We compared the following clinical outcomes: polyp/lesion recurrence rate & 5-yr all-cause mortality of EMR vs surgery patients. We compared healthcare utilization outcomes: procedure vs operating time; initial hospital length of stay (LOS); & ER visits based on intervention. The EMR cohort was assembled from 3 advanced endoscopists’ data, each with >10 yrs of practice; the surgical cohort, from relevant CPT codes.
Lesion recurrence rate was found through keyword search of adenoma or carcinoma within 18mo of EMR or surgery & confirmed with chart review. Mortality data was identified from California Death Registry. Healthcare utilization data including 30-d ER visit was identified from electronic medical records. Patients were censored at death, plan disenrollment, up to 5-yrs post-intervention, or study completion. Time-to-event analysis was performed using Kaplan-Meier with Multivariable Cox proportional hazard analysis adjusted for age, gender, Charlson comorbidity, & smoking.
Results
There were 2728 patients (620 EMR, 2108 surgery); median age was 67 yrs, 50.4% were men, & majority were White (54.9%) & Hispanic (22.4%). 91.6% of EMR were colon (568/620); 4% esophagus (25/620); 4.4% stomach (27/620). 97.4% of surgeries were colon (2054/2108); 1% esophagus (21/2108); 1.6% stomach (33/2108). In the EMR cohort, 22 (3.5%) patients failed & required surgery.
18-mo recurrence was higher in the EMR group (10.8% vs 0%, p<0.0001), with most recurrences managed endoscopically (50/67, 74.6%). Both groups had similar 30-day procedure-related comorbidity (1% vs 2%, p=0.077), but EMR showed a survival advantage (EMR overall mortality with adjusted hazard ratio of 0.627 [95% CI 0.477-0.824, p < 0.0008] vs surgery). See figure 1.
EMR was faster than surgery [mean 41.8mins (SD 25mins) vs 130.6mins (SD 71.3mins); p<0.0001]. Initial LOS was shorter for the EMR cohort vs surgical cohort [mean 0 days (SD 0.3 days) vs 5.8 days (SD 6.2 days); p<0.0001]. Both groups had similar 30-day post-procedure ER visits (0.6% vs 1.5%, p = 0.0941).
Conclusion
1. Both EMR & surgery have high 30-day safety
2. Utilization metrics favor EMR over surgery
3. For adenomatous/early-stage cancers, there appears to be a survival advantage of EMR over surgery
Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Background and Aim
Recently, advances have been made in image-enhanced endoscopy (IEE) technology and several methods that can be used in a clinical setting are available. Linked color imaging (LCI) is useful for surveillance endoscopy in high-risk patients; however, standard endoscopy is based on white light imaging (WLI) and IEE is not yet standard. Also, the superiority of narrow-band imaging (NBI), which was first developed, to WLI for detection of neoplastic lesions has not been clarified. The aim in this study was to verify the superiority of LCI to NBI for surveillance endoscopy using IEE.
Method
This study was conducted as an open-label, two-arm-parallel (1:1), multicenter, randomized controlled trial and registered in the Japan Registry of Clinical Trials (jRCT1012200006). Patients aged 20–85 years with a treatment history or with follow-up of epithelial tumors of the upper gastrointestinal tract who received surveillance endoscopy were recruited. Patients were assigned in a 1:1 ratio to an NBI group and an LCI group using a computerized minimization procedure. The endoscopy systems used were the LASEREO system (FUJIFILM Co., Tokyo, Japan) for LCI and the EVIS LUCERA ELITE system (Olympus Co., Tokyo, Japan) for NBI. According to randomization, endoscopic observation was performed with primary IEE followed by WLI (primary LCI and secondary WLI or primary NBI and secondary WLI). The primary endpoint was the detection rate of one or more epithelial neoplasms in the pharynx, esophagus and stomach, which was defined as the proportion of patients with tumors detected in the primary examination. The secondary endpoints included overlooked neoplastic lesions and procedure time.
Results
During the study period, a total of 372 patients in the NBI group and 378 patients in the LCI group in whom EGD was performed were analyzed. Neoplastic lesions were detected by NBI in 18 patients (4.6%) and were detected by LCI in 20 patients (5.3%) (P = 0.87). In secondary WLI, neoplastic lesions were detected in 11 patients in the NBI group (3.0%) and in 1 patient in the LCI group (0.27%) (P = 0.003). There was no significant difference between the two groups in the total number of neoplasms detected. Overlooked ratios were 36.7 % in primary NBI and 4.2% in primary LCI (P = 0.007). The mean observation times for primary IEE were 209.9 s in NBI and 215.3 s in LCI (P = 0.27).
Conclusions
LCI did not show superiority to NBI for detection of neoplastic lesions in high-risk patients. However, the percentage of overlooked lesions during primary NBI was significantly higher than that during primary LCI.
Background and study aim
Endoscopic ultrasound guided through-the-needle biopsy (EUS-TTNB) has improved the diagnostic algorithm of pancreatic cystic neoplasms (PCN). However, the fragments obtained are very small and sometimes not eye-visible with the risk of loss during the preparation process.
Fluorescence Confocal Laser Microscopy (FCM) allows imaging of tissues in the fresh state, requiring minimal preparation without damage or loss of tissue.
The primary aim of this study was to assess the feasibility of the FCM with MAVIG VivaScope® 2500M-G4 microscope on the fragment obtained from EUS TTNB. The secondary aim was to assess the concordance between the diagnosis with VivaScope® and the standard technique.
Methods
Single centre prospective study conducted on consecutive patients with PCN who underwent EUS-TTNB at the Endoscopy Unit of Campus Bio-Medico University hospital. A 19 G needle with pre-loaded micro-forcep was used in all cases. Obtained samples were placed directly in a dedicated scaffold (Cytomatrix, UCS Diagnostics) and evaluated at FCM and classified as “Inadequate” or “Adequate”. Adequate samples were classified as serous, mucinous or other on the sole basis of the morphological characteristics of the epithelial lining.
Results
From June 2021 to September 2022, 15 patients were enrolled.
Seven (47%) PCNs were located in the body of the pancreas, while 5 (33.3%) in the head and 3 (22%) in the tail. The mean size of PCNs was 39.2±8.8 mm.
At VivaScope® evaluation, the sample was defined adequate in 14/15 (93.3%).
Among the adequate samples, 10/14 (71.4%) was defined mucinous, 2/14 (14.3%) serous cystoadenoma, 1/14 (7.1%) pseudocyst and 1 (7.1%) neuroendocrine cystic tumour.
There was a good agreement between the VivaScope® diagnosis and the final histological diagnosis (kappa Cohen’s coefficient 1, p = 0.001).
When evaluating VivaScope®’s diagnostic performances the Sensitivity was 100%, 95% CI 76.8%-100%, the Specificity 100%, 95% CI 2.5%-100%, PPV 100%, NPV 100% and Accuracy 100% 95% CI 78.2-100%.
Conclusion
FCM represents a new technique successfully applicable to micro-histological specimens. It provides fast information about sample adequacy and diagnosis in small specimens with good agreement with the final histology. However, a larger sample is necessary to confirm these data.

Saturday
10:12am - 10:27am EDT - May 6, 2023 | Room: S101 (McCormick Place)
Society: ASGE
Type: Topic Forum
Society: ASGE


Background: GI endoscopy procedures are critical for the screening, diagnosis, and treatment of a variety of patient signs/symptoms. However, similar to other medical disciplines, they are a source of environmental waste generation and energy consumption in form of plastic, sharps, personal protective equipment (PPE), cleaning supplies and energy.

Methods: We prospectively collected data on total waste generation of a single large academic endoscopy unit over a 2-month period (May-June 2022). During this time period, detailed data on items used for every patient were collected from the point of patient entry to the endoscopy unit until discharge including procedure type, accessories used, IV tubing, number of biopsy jars, linen, PPE usage etc. In addition, reprocessing related waste generation for each procedure and energy utilization for the unit (endoscopy equipment, lights, computers etc.) for each day were also collected. The waste generated was stratified into biohazardous, non-biohazardous, or potentially recyclable items (to determine opportunities to improve/maximize recycling of waste). No patient information was collected, and the study was approved by the IRB.

Results: We prospectively analyzed waste generation for 450 consecutive procedures over a 2-month period. The total waste generated during this time period was 1398.6 kg - 61.6% directly going to landfill, 33.3% biohazard waste and 5.1% sharps. The average per procedure waste directly going to landfill was 2.19 kg which approximates to 9,189 kg for an entire year or 219 kg/100 procedures. 20% of the total waste generated was potentially recyclable (i.e. plastic CO2 tubing, O2 connector, syringes etc.). This could reduce total waste going to landfill by 8.6 kg per day (2,580 kg per year) or 61 kg per 100 procedures (Figure 1). Endoscope reprocessing generated 194 gallons of liquid waste (=735.26 kg.) per day or 1385 gallons per 100 procedures. In total, the annual waste generation approximated the size of 2 football fields. Finally, energy consumption in the endoscopy unit was 277.1 kW hour energy per day (=8.2 gallons of gasoline) or ~1980 kW hour per 100 procedures. Energy consumption for 100 procedure amounts to 1200 miles of distance (i.e. Seattle to San Diego) traveled by an average fuel efficiency car.

Conclusion: On average, every 100 routine GI endoscopy procedures (EGD/colonoscopy) are associated with 218 kg. landfill waste generation, and 2000kW hour energy consumption. Potentially recyclable materials account for 20% of the total waste – this can be a simple initial step to reduce waste going to landfill. These data could serve as an actionable model for health-systems to reduce total waste generation, landfill, and water waste towards environmentally sustainable endoscopy units.
Figure 1. Average daily waste distribution in the endoscopy unit

Figure 1. Average daily waste distribution in the endoscopy unit

Table 1. Total waste production and energy per day and per 100 procedures

Table 1. Total waste production and energy per day and per 100 procedures

Introduction
Adequate bowel preparation is essential for optimal visualization during a colonoscopy, yet inadequate bowel preparation (IBP) remains common despite preprocedural interventions and adherence to preparation protocols. Poor bowel preparation often leads to suboptimal or canceled procedures, causing frustration and lost opportunity time for patients and endoscopists alike. An FDA-approved, 3rd generation over-the-scope intraprocedural cleansing system could serve as a solution for IBP.

Methods
We performed a retrospective study at a Veteran Affairs (VA) hospital over a 12-month period comparing the adequacy of bowel preparation at the time of colonoscopy in the six months before and after the implementation of an intraprocedural cleansing system. IBP was defined as a Boston Bowel Preparation Score (BBPS) of < 6 or a bowel preparation described as poor or inadequate per the Aronchick scale.

Results
We studied a total of 2,367 colonoscopies over a 12-month period from 10/2021 to 9/2022, implementing the intraprocedural cleansing system in 4/2022. There were 1,198 pre-implementation cases from 10/2021-3/2022 and 1,169 post-implementation cases from 4/2022-9/2022. The cleansing system was utilized in 46 cases with an increase in use over time. The IBP rate decreased after the cleansing system was implemented with a pre-implementation IBP rate of 9.3% (111/1,198 cases) and a post-implementation IBP rate of 5.9% (69/1,169 cases) (Figure 1). Further analysis of the successful cases using the cleansing system (N=36) revealed a substantive increase in the adequacy of bowel preparation with the average BBPS improving from 4.8 to 8.7. Unsuccessful device cases were almost exclusively related to patient intolerance of sedation or anatomical reasons that precluded even a device-free colonoscope from passing.

Conclusion
This is the first study to compare the rates of inadequate bowel preparation before and after the implementation of an intraprocedural cleansing system. The rates of IBP decreased significantly following the implementation of the intraprocedural cleansing system. The use of this device is both feasible and results in improved bowel preparation rates. Better bowel preparation at the time of colonoscopy may have an important impact in terms of improved examination quality and patient experience, longer duration of surveillance colonoscopy intervals, and decreased suboptimal or canceled procedures with better resource utilization.
<b>Figure 1</b>: The monthly rate of inadequate bowel preparation before <i>(blue)</i> and after (<i>orange)</i> implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Figure 1: The monthly rate of inadequate bowel preparation before (blue) and after (orange) implementation of the intraprocedural cleansing system. Overall, we saw a decrease in the average rate of inadequate bowel preparation from 9.3% in the six months preceding the implementation of the device to 5.9% in the six months following the implementation of the device.

Background: Apart from adequate bowel preparation, colonic spasm is one of the significant problems that impair visualization during colonoscopy, and might affects the adenoma detection rate (ADR). When glucagon is not available, hyoscine was used to reduce colonic spasms with concerning adverse effects. In vitro research showed peppermint oil (PO) to be effective in relaxing colonic smooth muscle. Previous studies revealed the heterogeneous outcome of intraluminal PO on colonic spasms and ADR.
Aim: To investigate the efficacy of intraluminal PO on colonic peristalsis, ADR, polyp detection rate (PDR), adenoma per positive participants (APP), and safety.
Study design: A prospective, randomized, double-blinded, placebo-controlled trial was conducted. Of 408 patients, randomization to receive either a 50 ml solution of 1.6% PO plus simethicone (PO group) or simethicone alone (placebo group). All patients undergoing colonoscopy under propofol and/or fentanyl sedation supervised by an anesthesiologist. After the cecum was reached, the baseline colonic peristalsis score (0-3) was recorded. Then, the solution was infused through the scope channel over the cecum. The peristalsis score was graded again 30 seconds later and at the end of the procedure. An additional dose of solution or intravenous hyoscine can be requested if there is an inadequate response. Room air insufflation was used during scope withdrawal. Outcomes including ADR, APP, improvement of colonic peristalsis after spraying, procedure time, hemodynamic change, and patients’ symptoms after colonoscopy was assessed.
Results: The mean age was 60, and 67% were female. The patient’s characteristics were comparable among the two groups, and most of them achieved adequate bowel preparation (Table 1). Overall, ADR was 41.2%, and no difference was observed among the two groups (42.2% in PO vs. 40.2% in placebo, p=0.69). PDR (56.4% in PO vs. 55.9% in placebo, p=0.92) and APP (2.36 in PO vs. 2.21 in placebo, p= 0.23) were also no significant difference (Fig1a). The at least 1-grade improvement of peristalsis after the 1st spray was comparable between the two groups (Fig 1b). Interestingly, the overall mild or no peristalsis (score 0-1) was significantly higher in the placebo group (83.8% vs. 77.7%, p=0.006). Hyoscine was infrequently used, and no significant adverse events occurred in both group.
Conclusion: This randomized, double-blinded study failed to demonstrate the significant benefit of intraluminal PO in reducing colonic peristalsis or increasing ADR. However, overall peristalsis was gentle, and ADR was adequate. Further study to evaluate the appropriate dose and administration of PO is warranted.
Table 1. Patient’s characteristics and outcomes

Table 1. Patient’s characteristics and outcomes

INTRODUCTION
Different virtual chromoendoscopy techniques to enhance imaging have shown controversial results in increasing Adenoma Detection Rate (ADR) during colonoscopy. A new imaging modality, Texture and Color Enhancing Imaging (TXI, Exera X1, Olympus, Japan) was recently proposed as a substitute to standard high definition white light (WLI) colonoscopy, but no study has assessed its efficacy in a clinical trial. We performed an international, multicenter randomized trial to assess the efficacy of TXI in detection of colorectal neoplasia.
METHODS
We enrolled consecutive patients >40 years old undergoing screening, surveillance or diagnostic colonoscopies at 5 centers (Italy, Germany, Japan) from September 2021 through May 2022. Patients were randomly assigned (1:1) to groups undergoing colonoscopies with TXI or WLI (controls). The primary outcome was adenoma detection rate (ADR, the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy (APC), and withdrawal time. Adjusted Odds Ratios (OR) for age, sex and colonoscopy indication were calculated.
RESULTS
We enrolled a total 747 patients, [11 expert endoscopists (mean age: 62.9±9.08 years)]. ADR was statistically significantly higher in the TXI group (221/375, 58.9%) than in the WLI group (159/372, 42.7%; adjusted RR: 1.35; 95% CI:1.17 to 1,56), as well as APC (1.36 ± 1.79 vs 0.89 ± 1.35; incident rate ratio, 1.53 [95% CI:1.25; 1.88]). No statistically significant difference in withdrawal time (TXI: 7.76±2.09 minutes vs WLI: 8.07 ±1.78; p = ns) was observed. No difference between TXI and control was observed in term of adequate (Boston Bowel Preparation Scale >2 in all colonic segments) cleansing (363/375, 96.8% vs 351/372, 94.4%) and cecal intubation rate (366/375 subjects, 97.6% vs 365/372, 98.1%).
CONCLUSIONS
In a multicenter randomized trial, we found that TXI increased ADR and APC in a non selected population of patients undergoing colonoscopy for various indications. TXI was associated with increased detection of polyps <10mm in size, both in the proximal and in the distal colon. The use of TXI during colonoscopy may be of benefit to increase colonoscopy quality indicators.
Introduction
Endoscopic mucosal resection is an established treatment for adenomatous or early-stage cancers in the GI tract. However, the comparative effectiveness of EMR vs surgery in a real-world setting has not been fully established. We compared clinical outcomes & healthcare utilization between EMR vs surgery.
Methods
This was a retrospective cohort study of patients in a US-based health care organization. Patients 18-85yo were included if they had adenomas or early-stage cancer (T1N0) in the colon, esophagus, or stomach; had EMR or surgery from 1/1/08-12/31/17; & had ≥ 12 months of continuous membership post-intervention.
We compared the following clinical outcomes: polyp/lesion recurrence rate & 5-yr all-cause mortality of EMR vs surgery patients. We compared healthcare utilization outcomes: procedure vs operating time; initial hospital length of stay (LOS); & ER visits based on intervention. The EMR cohort was assembled from 3 advanced endoscopists’ data, each with >10 yrs of practice; the surgical cohort, from relevant CPT codes.
Lesion recurrence rate was found through keyword search of adenoma or carcinoma within 18mo of EMR or surgery & confirmed with chart review. Mortality data was identified from California Death Registry. Healthcare utilization data including 30-d ER visit was identified from electronic medical records. Patients were censored at death, plan disenrollment, up to 5-yrs post-intervention, or study completion. Time-to-event analysis was performed using Kaplan-Meier with Multivariable Cox proportional hazard analysis adjusted for age, gender, Charlson comorbidity, & smoking.
Results
There were 2728 patients (620 EMR, 2108 surgery); median age was 67 yrs, 50.4% were men, & majority were White (54.9%) & Hispanic (22.4%). 91.6% of EMR were colon (568/620); 4% esophagus (25/620); 4.4% stomach (27/620). 97.4% of surgeries were colon (2054/2108); 1% esophagus (21/2108); 1.6% stomach (33/2108). In the EMR cohort, 22 (3.5%) patients failed & required surgery.
18-mo recurrence was higher in the EMR group (10.8% vs 0%, p<0.0001), with most recurrences managed endoscopically (50/67, 74.6%). Both groups had similar 30-day procedure-related comorbidity (1% vs 2%, p=0.077), but EMR showed a survival advantage (EMR overall mortality with adjusted hazard ratio of 0.627 [95% CI 0.477-0.824, p < 0.0008] vs surgery). See figure 1.
EMR was faster than surgery [mean 41.8mins (SD 25mins) vs 130.6mins (SD 71.3mins); p<0.0001]. Initial LOS was shorter for the EMR cohort vs surgical cohort [mean 0 days (SD 0.3 days) vs 5.8 days (SD 6.2 days); p<0.0001]. Both groups had similar 30-day post-procedure ER visits (0.6% vs 1.5%, p = 0.0941).
Conclusion
1. Both EMR & surgery have high 30-day safety
2. Utilization metrics favor EMR over surgery
3. For adenomatous/early-stage cancers, there appears to be a survival advantage of EMR over surgery
Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Figure 1: 5 year overall mortality with number of patients at risk per year for both EMR and surgery cohorts.

Background and Aim
Recently, advances have been made in image-enhanced endoscopy (IEE) technology and several methods that can be used in a clinical setting are available. Linked color imaging (LCI) is useful for surveillance endoscopy in high-risk patients; however, standard endoscopy is based on white light imaging (WLI) and IEE is not yet standard. Also, the superiority of narrow-band imaging (NBI), which was first developed, to WLI for detection of neoplastic lesions has not been clarified. The aim in this study was to verify the superiority of LCI to NBI for surveillance endoscopy using IEE.
Method
This study was conducted as an open-label, two-arm-parallel (1:1), multicenter, randomized controlled trial and registered in the Japan Registry of Clinical Trials (jRCT1012200006). Patients aged 20–85 years with a treatment history or with follow-up of epithelial tumors of the upper gastrointestinal tract who received surveillance endoscopy were recruited. Patients were assigned in a 1:1 ratio to an NBI group and an LCI group using a computerized minimization procedure. The endoscopy systems used were the LASEREO system (FUJIFILM Co., Tokyo, Japan) for LCI and the EVIS LUCERA ELITE system (Olympus Co., Tokyo, Japan) for NBI. According to randomization, endoscopic observation was performed with primary IEE followed by WLI (primary LCI and secondary WLI or primary NBI and secondary WLI). The primary endpoint was the detection rate of one or more epithelial neoplasms in the pharynx, esophagus and stomach, which was defined as the proportion of patients with tumors detected in the primary examination. The secondary endpoints included overlooked neoplastic lesions and procedure time.
Results
During the study period, a total of 372 patients in the NBI group and 378 patients in the LCI group in whom EGD was performed were analyzed. Neoplastic lesions were detected by NBI in 18 patients (4.6%) and were detected by LCI in 20 patients (5.3%) (P = 0.87). In secondary WLI, neoplastic lesions were detected in 11 patients in the NBI group (3.0%) and in 1 patient in the LCI group (0.27%) (P = 0.003). There was no significant difference between the two groups in the total number of neoplasms detected. Overlooked ratios were 36.7 % in primary NBI and 4.2% in primary LCI (P = 0.007). The mean observation times for primary IEE were 209.9 s in NBI and 215.3 s in LCI (P = 0.27).
Conclusions
LCI did not show superiority to NBI for detection of neoplastic lesions in high-risk patients. However, the percentage of overlooked lesions during primary NBI was significantly higher than that during primary LCI.
Background and study aim
Endoscopic ultrasound guided through-the-needle biopsy (EUS-TTNB) has improved the diagnostic algorithm of pancreatic cystic neoplasms (PCN). However, the fragments obtained are very small and sometimes not eye-visible with the risk of loss during the preparation process.
Fluorescence Confocal Laser Microscopy (FCM) allows imaging of tissues in the fresh state, requiring minimal preparation without damage or loss of tissue.
The primary aim of this study was to assess the feasibility of the FCM with MAVIG VivaScope® 2500M-G4 microscope on the fragment obtained from EUS TTNB. The secondary aim was to assess the concordance between the diagnosis with VivaScope® and the standard technique.
Methods
Single centre prospective study conducted on consecutive patients with PCN who underwent EUS-TTNB at the Endoscopy Unit of Campus Bio-Medico University hospital. A 19 G needle with pre-loaded micro-forcep was used in all cases. Obtained samples were placed directly in a dedicated scaffold (Cytomatrix, UCS Diagnostics) and evaluated at FCM and classified as “Inadequate” or “Adequate”. Adequate samples were classified as serous, mucinous or other on the sole basis of the morphological characteristics of the epithelial lining.
Results
From June 2021 to September 2022, 15 patients were enrolled.
Seven (47%) PCNs were located in the body of the pancreas, while 5 (33.3%) in the head and 3 (22%) in the tail. The mean size of PCNs was 39.2±8.8 mm.
At VivaScope® evaluation, the sample was defined adequate in 14/15 (93.3%).
Among the adequate samples, 10/14 (71.4%) was defined mucinous, 2/14 (14.3%) serous cystoadenoma, 1/14 (7.1%) pseudocyst and 1 (7.1%) neuroendocrine cystic tumour.
There was a good agreement between the VivaScope® diagnosis and the final histological diagnosis (kappa Cohen’s coefficient 1, p = 0.001).
When evaluating VivaScope®’s diagnostic performances the Sensitivity was 100%, 95% CI 76.8%-100%, the Specificity 100%, 95% CI 2.5%-100%, PPV 100%, NPV 100% and Accuracy 100% 95% CI 78.2-100%.
Conclusion
FCM represents a new technique successfully applicable to micro-histological specimens. It provides fast information about sample adequacy and diagnosis in small specimens with good agreement with the final histology. However, a larger sample is necessary to confirm these data.