BMJ Open Gastroenterology最新文献

Objectives: Colorectal cancer screening with flexible sigmoidoscopy focuses on the distal colorectum, but it is unclear which distal polyp characteristics are associated with future proximal colon cancer incidence. We examined associations between distal adenoma or hyperplastic polyp characteristics and long-term incident proximal colon cancer.

Methods: In secondary, observational analyses of UK Flexible Sigmoidoscopy Screening Trial data, we obtained data on the number and size of distal hyperplastic polyps (n=4872) and adenomas (n=4581), adenoma histology and dysplasia from endoscopy and pathology reports for screened asymptomatic participants. Adjusted HRs and 95% CIs for the association between distal polyp characteristics and proximal colon cancer incidence were estimated using multivariable Cox proportional hazard models.

Results: Over a median of 20.7 years of follow-up (IQR 16.5-21.7), 110 proximal colon cancers were diagnosed among participants with distal adenomas and 96 were diagnosed among those with only distal hyperplastic polyps detected at baseline. Larger adenoma size (6-9 mm vs ≤5 mm: HR 1.67 (95%CI: 1.07 to 2.59) and ≥10 mm vs ≤5 mm: HR 2.08 (95%CI: 0.98 to 4.43); p=0.037) and high-grade (vs low-grade) adenoma dysplasia (HR 2.82, 95% CI: 1.34 to 5.93; p=0.012) at baseline were positively associated with proximal colon cancer incidence. No associations were observed for distal adenoma number overall or histology, or the number or size of hyperplastic polyps and proximal colon cancer incidence.

Conclusions: We found some evidence that larger distal adenomas and those with high-grade dysplasia at baseline were positively associated with proximal colon cancer incidence. Larger studies are needed to confirm these findings.

Trial registration number: ISRCTN28352761.

Objective: The advent of biological drugs has revolutionised management of inflammatory bowel disease (IBD). However, the extent to which these novel pharmacological drugs have reduced the need for surgical treatment remains incompletely quantified.We aimed to investigate the risk of first, major surgery in IBD in a population-based, large epidemiological study.

Methods: We empanelled a cohort comprising all 85 974 patients diagnosed with ulcerative colitis (UC) and 42 760 with Crohn's disease (CD) in Norway and Sweden in 1987 through 2017. We used log-rank tests to compare the cumulative probability of surgical treatment for UC and CD. Using multivariable Cox proportional hazards models, we estimated hazard ratios (HR) with 95% CIs by year of diagnosis, age, sex and extent of disease.

Results: During a mean follow-up of 9.9 years, surgery was undertaken in 11 187 (13.0%) patients with UC (12.3 per 1000 person-years) and in 11 307 (26.4%) patients with CD (30.0 per 1000 person-years). In UC, the cumulative 5-year probability of surgery decreased from 16.2% in patients diagnosed in 1987-1994 to 5.8% in those diagnosed in 2011-2017 (p<0.001). In CD, the corresponding decline was from 30.1% to 13.9% (p<0.001). In multivariable analyses, the likelihood of surgical treatment decreased during the study period by 61% (HR 0.39, 95% CI 0.36 to 0.42) in UC and by 31% (HR 0.69, 95% CI 0.65 to 0.75) in CD.

Conclusions: Following the introduction of biologic drugs, the need for surgical treatments has been dramatically reduced in patients with UC and moderately reduced in patients with CD.

Objectives: The top 10 research priorities (RPs) for Barrett's oesophagus (BO) were published in 2017. This study aimed to identify the current research landscape on addressing RPs.

Design: Systematic mapping review.

Data sources: ClinicalTrials.gov, EU Clinical Trials Register and ISRCTN registry.

Eligibility criteria: Adult (>18 years) interventional studies registered in those three registers from 31 August 2017 to 1 July 2024 and addressing any of the top 10 RPs were eligible.

Data extraction and synthesis: Two researchers extracted data using prespecified tables, from the three registers and pooled them together.

Results: We identified clinical trials (n=735) registered in the last 7 years (ClinicalTrials.gov (611), EU Clinical Trials (63), ISRCTN (61)), and 244 were included as they addressed RPs, after removing 14 duplicates. Most studies (168/244, 69%) addressed RP8 (searching alternative treatments for reflux), including medicinal products (86/168 (51%)), surgical methods (29/168 (17%)) and endoscopic methods (26/168 (15%)). There were 41/244 (17%) trials registered aiming investigations for screening and surveillance of BO in a primary care setting (RP3). 92% of studies were distributed among RP8, RP3 and RP5. The remaining RPs (RP1, RP2, EP4, RP6, RP7 and RP9) had only 8% of 244 studies, while the RP10 had none.

Conclusion: A higher concentration of studies on RP8, RP3 and RP5 may demonstrate the high clinical and global commercial demand on them, while the scarcity of trials for RP1, RP2, RP4, RP6, RP7, RP9 and RP10 unveils gaps in research meeting priorities. This unequal distribution of the trial landscape raises the question: do we correctly address the RPs?

Objective: To compare water-assisted colonoscopy (WAC) using the water immersion technique with conventional carbon dioxide insufflation colonoscopy (CC) in novice endoscopists, focusing on procedure time, safety and learning curves.

Methods: We conducted a prospective, randomised (1:1), single-centre trial at Chiang Mai University Hospital, Thailand. Six gastroenterology fellows with <150 prior colonoscopies received standardised training before performing elective screening colonoscopies using either WAC or CC techniques. Patients were randomly assigned to WAC or CC groups. The primary outcome was caecal intubation time (CIT). Secondary outcomes included technical failure, procedural difficulty, patient discomfort, complications, withdrawal time and adenoma detection rate (ADR).

Results: Of 250 randomised patients, 230 completed the protocol (WAC, n=113; CC, n=117). Mean CIT was comparable between groups (10.6±4.2 min vs 9.8±3.9 min; p=0.35). Technical failure occurred in 6.2% of WAC and 5.1% of CC procedures, with no significant differences in procedural difficulty ratings, analgesic requirements or patient discomfort scores. ADR was similar between arms (40.7% vs 33.3%; p=0.25). Learning curves demonstrated parallel, progressive reductions in CIT among fellows in both groups.

Conclusion: WAC is a safe and effective alternative to CC for novice endoscopists, with similar procedure times, learning curves and safety profiles. These findings support the inclusion of WAC in gastroenterology training programmes.

Trial registration number: TCTR20230324001.

Objective: This study evaluates the experiences, perceptions, and attitudes of people with Lynch syndrome (LS) towards faecal immunochemical testing (FIT) as an adjunct to colonoscopy for colorectal cancer surveillance.

Methods: A mixed-methods design included two cohorts: an emergency clinical service during the COVID-19 pandemic and a longitudinal research initiative. Paper-based surveys assessed user experiences and attitudes using Likert scales and open-ended questions. Quantitative data were analysed for response patterns, while thematic analysis explored qualitative feedback.

Results: Among 85% of participants who rated FIT positively, 90% were confident in using the test correctly. Women reported higher anxiety (7.8%) compared with men (2.0%, p=0.045). Thematic analysis revealed gratitude for FIT's convenience during healthcare disruptions but emphasised concerns about its accuracy.

Conclusions: FIT is widely perceived as an acceptable supplemental tool among surveyed people with LS, who appreciate its potential to reduce intervals between colonoscopies without compromising surveillance quality. Ongoing patient engagement is crucial to addressing concerns about FIT's reliability. Future research should evaluate long-term outcomes and explore diverse population perspectives to guide FIT implementation in LS surveillance.

Objective: To assess the safety and quality of baseline screening colonoscopy in a randomised controlled trial (RCT).

Methods: A population-based RCT with an explanatory design is ongoing to evaluate the efficacy of colonoscopy screening in 9751 men and women aged 40-74 years at average risk of colorectal cancer (CRC) in Japan. Screening colonoscopies for the intervention group were performed from June 2009 to June 2017.

Results: Of the 4861 participants in the intervention group, 4495 (92.5%) underwent screening colonoscopy. The quality of bowel preparation was excellent (34.8%) or good (45.6%) in 80.4% of cases. The caecal intubation rate was 99.7% (4483/4495), and the mean (±SD) withdrawal time was 9.7 (±5.3) min. The adenoma detection rate (ADR) was 39.4% (1770/4495). A total of 27 participants (0.6%) were diagnosed with CRC, and 266 (5.9%) were diagnosed with advanced neoplasia (AN). In women, adenomas were more frequently detected in the proximal colon than in the distal colon (proximal: 18.9% vs distal: 16.4%, p=0.024), and a similar trend was observed for AN (proximal: 2.4% vs distal: 1.5%, p=0.045). No serious adverse events related to screening colonoscopy were reported, and minor adverse events were observed in two participants (0.04%).

Conclusions: Adequate performance in compliance, ADR, and safety was confirmed in the intervention arm of the RCT evaluating the efficacy of screening colonoscopy. The high quality of screening colonoscopy observed in the trial suggests its feasibility as a population-based screening approach.

Trial registration number: UMIN000001980.

Objectives: In many countries, single-use endoscopy accessories such as forceps have almost replaced their reusable counterparts. We reviewed the evidence on the broader economic cost and environmental impacts associated with single-use and multiple-use accessories for gastrointestinal (GI) endoscopes.

Design: Systematic review following the reporting guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Data sources: MEDLINE, Embase, Web of Science and Cochrane Database of Systematic Reviews were searched from 1 January 2000 to 25 September 2024.

Eligibility criteria: We included published economic evaluations on single-use and reusable GI endoscope accessories which were written in English.

Data extraction and synthesis: Two independent reviewers extracted data and quality-assessed identified studies according to the Consensus on Health Economic Criteria checklist.

Results: Seven economic analyses were included: all were cost analyses. Three studies were from the USA, three from Europe and one from Korea. Patients in these studies underwent GI endoscopy (n=3), colonoscopy (n=2), gastroscopy (n=1) and endoscopic retrograde cholangiopancreatography (n=1). All studies compared single-use with reusable accessories, of which six were forceps. Reprocessing and purchase costs were included in all studies, repair costs were included in three studies, and environmental impact was only considered in one study. Most studies (n=5) reported a higher cost per procedure associated with single-use accessories.

Conclusions: Apart from two studies, all studies indicated that the cost per procedure was greater using single-use accessories/forceps. Future economic evaluations of single versus reusable accessories/forceps should include costs and also consequences of health and beyond, especially environmental impact.

Objective: This cost-effectiveness analysis compares vonoprazan against lansoprazole, a gold-standard proton pump inhibitor, in managing erosive oesophagitis.

Methods: The economic evaluation was carried out using data from a double-blind, randomised control trial. Costs were measured in pounds sterling. Effectiveness was assessed on a binary scale, resolution versus non-resolution of disease, after 32 weeks.

Results: The primary analysis produced an incremental cost-effectiveness ratio (ICER) of £3421.27 per resolution. After applying quality-adjusted life year (QALY) data from the REFLUX trial (2008), we derived an ICER/QALY of £34 747.32, marginally exceeding the £30 000 threshold set by the National Institute for Health and Care Excellence. However, further subgroup analysis showed cost-effectiveness when healing severe grades of oesophagitis (ICER/QALY of £22 165.56). The first sensitivity analysis considers the typically non-invasive determination of disease resolution; the ICER/QALY of £15 826.98 supports vonoprazan's use in treating severe oesophagitis. The second considers a longer healing phase alongside a stronger 30 mg maintenance dose of lansoprazole, concordant with current guidelines; the ICER/QALY of £43 998.39 suggests the guidelines (regarding dosage, frequency and duration) must be optimised for vonoprazan. The final sensitivity analysis accounts for variations in quality-of-life measures, which grossly inflate the ICER/QALY (£118 216.32); this emphasises that vonoprazan should mainly be considered for patients with persistent symptoms and high severity.

Conclusion: Vonoprazan is potentially cost-effective for the initial healing of severe oesophagitis, after endoscopic diagnosis. Further trials and economic evaluations are necessary for the symptom-based prescription of vonoprazan and to determine the optimal dosage, frequency and duration.