Implementation of endoscopic submucosal dissection in Europe: survey after ten ESD expert training workshops 2009 – 2018

Background and aims Transfer of ESD technique for early gastrointestinal cancer from Japan requires expert-supervised experimental training before unsupervised implementation of clinical ESD. Aims To evaluate unsupervised implementation of ESD-intention-to-treat (-ITT). Methods ESD Workshops (in-vivo porcine model) lasted 3.3 days including one day theory for 177 participants from 135 Western referral centers. A questionnaire was sent to the senior participant of all 135 centers. Design Cross-sectional questionnaire survey. Main outcome measurements Performance, organ distribution, severe adverse events of ESD-ITT. Results Feedback was received from 113 centers (84%), i.e. 73 (54%) ESD centers and 40 centers (30%) with zero ESD; 10 (7%) had published ESD; no feedback from 12 (9%) centers with unknown status. Altogether, 83 centers (61.5%) perform ESD: 21 (16%) had >150 ESD (professional category), 33 (24%) had 31-150 ESD (competent category), and 29 (21.5%) had ≤ 30 ESD (initial learning category). Most implemented ESD centers (91%, 72 of 79) were analyzed: Centers on initial learning (420 ESD) compared to centers with >30 ESD (5676 ESD) performed en-bloc ESD in 64% vs. 84%, hybrid-ESD in 26% vs.11% and piecemeal-EMR in 10% vs. 5.2%. Majority of ESD (66-68%) were in colorectum, overall with low risk (30-day mortality 0.03%, surgical repair 3.5% vs. 1.7%) and satisfactory outcome (oncosurgery 7.4% vs. 5.2%, local recurrence 1.5% vs. 0.3%). Conclusions Beyond guideline recommendations, unsupervised implementation of ESD was successful in colorectum with step-up approach. Now, Western ESD centers have to aim for professional (i.e. >80%) curative ESD

The VITRO Score (Von Willebrand Factor Antigen/Thrombocyte Ratio) as a New Marker for Clinically Significant Portal Hypertension in Comparison to Other Non-Invasive Parameters of Fibrosis Including ELF Test

<div><p>Background</p><p>Clinically significant portal hypertension (CSPH), defined as hepatic venous pressure gradient (HVPG) ≥10 mmHg, causes major complications. HVPG is not always available, so a non-invasive tool to diagnose CSPH would be useful. VWF-Ag can be used to diagnose. Using the VITRO score (the VWF-Ag/platelet ratio) instead of VWF-Ag itself improves the diagnostic accuracy of detecting cirrhosis/ fibrosis in HCV patients.</p><p>Aim</p><p>This study tested the diagnostic accuracy of VITRO score detecting CSPH compared to HVPG measurement.</p><p>Methods</p><p>All patients underwent HVPG testing and were categorised as CSPH or no CSPH. The following patient data were determined: CPS, D’Amico stage, VITRO score, APRI and transient elastography (TE).</p><p>Results</p><p>The analysis included 236 patients; 170 (72%) were male, and the median age was 57.9 (35.2–76.3; 95% CI). Disease aetiology included ALD (39.4%), HCV (23.4%), NASH (12.3%), other (8.1%) and unknown (11.9%). The CPS showed 140 patients (59.3%) with CPS A; 56 (23.7%) with CPS B; and 18 (7.6%) with CPS C. 136 patients (57.6%) had compensated and 100 (42.4%) had decompensated cirrhosis; 83.9% had HVPG ≥10 mmHg. The VWF-Ag and the VITRO score increased significantly with worsening HVPG categories (P<0.0001). ROC analysis was performed for the detection of CSPH and showed AUC values of 0.92 for TE, 0.86 for VITRO score, 0.79 for VWF-Ag, 0.68 for ELF and 0.62 for APRI.</p><p>Conclusion</p><p>The VITRO score is an easy way to diagnose CSPH independently of CPS in routine clinical work and may improve the management of patients with cirrhosis.</p></div

ROC analysis shows the ability of aspartate aminotransferase to platelet ratio index (APRI) predicting clinically significant portal hypertension (CSPH).

<p>ROC analysis showing the diagnostic ability of APRI detecting CSPH with an AUC of 0.62.</p

Correlation of Von Willebrand factor antigen (vWF-Ag) and CSPH.

<p>Mean values of vWF-Ag shown in boxplots for a cohort of patients with and without CSPH each.</p

Median values of laboratory parameters and scores according to the Child-Pugh score, D’Amico staging (compensated and decompensated cirrhotic patients) and the extent of portal hypertension.

<p>Median values of laboratory parameters and scores according to the Child-Pugh score, D’Amico staging (compensated and decompensated cirrhotic patients) and the extent of portal hypertension.</p

Correlation of transient elastography (TE; kPa) and CSPH.

<p>Mean values of TE shown in boxplots for a cohort of patients with and without CSPH each.</p

Correlation of aspartate aminotransferase to platelet ratio index (APRI) and CSPH.

<p>Mean values of APRI shown in boxplots for a cohort of patients with and without CSPH each.</p

Correlation of enhanced liver fibrosis test (ELF) test and CSPH.

<p>Mean values of ELF test shown in boxplots for a cohort of patients with and without CSPH each.</p

ROC analysis shows the ability of VITRO (VWF-Ag/platelets) score predicting clinically significant portal hypertension (CSPH).

<p>ROC analysis showing the diagnostic ability of VITRO score detecting CSPH with an AUC of 0.86.</p