Krish Ragunath

Clinical and translational gastroenterology • October 01, 2024

Marcin Romańczyk, Madhav Desai, Michal Kamiński, Seiichiro Abe, Asma Alkandari, Torsten Beyna, Raf Bisschops, Krzysztof Budzyń, Monika Bugdol, Samir Grover, C Gyawali, Haruhiro Inoue, Prasad Iyer, Helmut Messmann, Krish Ragunath, Yutaka Saito, Sachin Srinivasan, Christopher Teshima, Rena Yadlapati, Cesare Hassan, Prateek Sharma

Introduction: The performance of a high quality esophagogastroduodenoscopy (EGD) is dependent on the mucosal cleanliness. Recently, the Polprep: Effective Assessment of Cleanliness in EGD (PEACE) scale was created to assess the degree of mucosal cleanliness during EGD. The aim of this study was to validate this scoring system in a cohort of international endoscopists. Methods: In total, 39 EGD videos, with different degrees of mucosal cleanliness were retrieved from a previously conducted prospective trial. All experts rated the cleanliness of the mucosa on each video using the PEACE scale. To evaluate agreement of all scores (0-3), intraclass correlation coefficient 2.1 was used. The agreement on adequate (scores 2 and 3) and inadequate (scores 0 and 1) cleanliness was assessed using kappa values. Results: Videos evaluating esophagus, stomach, and duodenum cleanliness were reviewed by 16 endoscopists. The PEACE scores demonstrated good agreement (intraclass correlation coefficient 0.82, 95% CI 0.75-0.89), especially for esophagus (0.84; 95% CI 0.71-0.95) and stomach (0.81; 95% CI 0.69-0.91), while agreement was moderate for the duodenum (0.69; 95% CI 0.51-0.87). The agreement was similar between Eastern (0.86; 95% CI 0.79-0.92) and Western experts (0.80; 95% CI 0.72-0.88). Similarly, agreement regarding adequate cleanliness was comparable between Eastern (0.70; 95% CI 0.55-0.85) and Western (0.74; 95% CI 0.64-0.84) endoscopists being overall 0.75 (95% CI 0.65-0.85). Discussion: The PEACE scoring system is a simple and reliable scale to assess the cleanliness during EGD. The score is now validated among international experts with high concordance, justifying its use in clinical practice.

Journal Of Gastroenterology And Hepatology • December 15, 2024

Linda Yang, Abir Halder, Bronte Holt, Benedict Devereaux, Matthew Remedios, Neil Merrett, Marianne Lill, Zoe Raos, Malcolm Arnold, Nicholas Burgess, Sneha John, Krish Ragunath

Quality standards for upper gastrointestinal (UGI) endoscopy are required to identify key quality indicators that are relevant to Australasian endoscopic practice and local patient populations. Such standards will promote equitable access to high-quality UGI endoscopy for appropriate indications across Australia and Aotearoa New Zealand. The Gastroenterological Society of Australia (GESA) Endoscopy Faculty's quality of UGI endoscopy working group conducted a review of published guidelines on quality standards in UGI endoscopy. A literature search was performed using the MEDLINE database, with further references sourced from bibliographies of published papers. Recommendations from international guidelines and available evidence were reviewed, and their relevance to the Australian clinical context was assessed. The working group then formulated a position statement on quality assurance in UGI endoscopy in Australian practice. A further iterative process involving the Endoscopy Guidance Group for New Zealand (EGGNZ) and the Royal Australasian College of Surgeons (RACS) culminated in the final recommendations for practice in Australia and Aotearoa New Zealand. The recommendations in this position statement are categorized into preprocedural, intraprocedural, and postprocedural. As UGI endoscopy examines several anatomical structures and is performed for a wider range of indications than colonoscopy, disease-specific intraprocedural recommendations for common benign and premalignant conditions of the UGI tract are also presented. This GESA initiative was undertaken in collaboration with the RACS and endorsed by GESA, RACS, the Royal Australasian College of Physicians, and EGGNZ, membership of which includes the New Zealand Society of Gastroenterology, the New Zealand Association of General Surgeons, and other local endoscopy stakeholders.

Endoscopy • August 21, 2024

Background:  Piecemeal endoscopic mucosal resection (EMR) is an acceptable technique for T1a esophageal adenocarcinoma, but en bloc R0 excision is advocated for T1b disease as it may offer a potential cure and mitigate recurrence. Thus, distinguishing between T1a and T1b disease is imperative under current treatment paradigms. We investigated whether expert Barrett's endoscopists could make this distinction based on optical evaluation. Methods:  Endoscopic images of histologically confirmed high grade dysplasia (HGD), T1a, and T1b disease (20 sets for each) were compiled from consecutive patients at a single institution. Each set contained four images including an overview, a close-up in high definition white light, a near-focus magnification image, and a narrow-band image. Experts predicted the histology for each set. Results:  19 experts from 8 countries (Australia, USA, Italy, Netherlands, Germany, Canada, Belgium, and Portugal) participated. The majority had been practicing for > 20 years, with a median (interquartile range) annual case volume of 50 (18-75) for Barrett's EMR and 25 (10-45) for Barrett's endoscopic submucosal dissection. Esophageal adenocarcinoma (T1a/b) could be distinguished from HGD with a pooled sensitivity of 89.1 % (95 %CI 84.7-93.4). T1b adenocarcinoma could be predicted with a pooled sensitivity of 43.8 % (95 %CI 29.9-57.7). Fleiss' kappa was 0.421 (95 %CI 0.399-0.442; P < 0.001), indicating fair-to-moderate agreement. Conclusions:  Expert Barrett's endoscopists could reliably differentiate T1a/T1b esophageal adenocarcinoma from HGD. Despite fair-to-moderate agreement for T staging, T1b disease could not be reliably distinguished from T1a disease. This may impact clinical decision making and selection of endoscopic techniques.

Endoscopy • May 03, 2024

Shyam Menon, Richard Norman, Prasad Iyer, Krish Ragunath

Background: Surveillance of nondysplastic Barrett's esophagus (NDBE) is recommended to identify progression to dysplasia; however, the most cost-effective strategy remains unclear. Mutation of TP53 or aberrant expression of p53 have been associated with the development of dysplasia in BE. We sought to determine if surveillance intervals for BE could be stratified based on p53 expression. Methods: A Markov model was developed for NDBE. Patients with NDBE underwent p53 immunohistochemistry (IHC) and those with abnormal p53 expression underwent surveillance endoscopy at 1 year, while patients with normal p53 expression underwent surveillance in 3 years. Patients with dysplasia underwent endoscopic therapy and surveillance. Results: On base-case analysis, the strategy of stratifying surveillance based on abnormal p53 IHC was cost-effective relative to conventional surveillance and a natural history model, with an incremental cost-effectiveness ratio (ICER) of $8258 for p53 IHC-based surveillance. Both the conventional and p53-stratified surveillance strategies dominated the natural history model. On probabilistic sensitivity analysis, the p53 IHC strategy ($28 652; 16.78 quality-adjusted life years [QALYs]) was more cost-effective than conventional surveillance ($25 679; 16.17 QALYs) with a net monetary benefit of $306 873 compared with conventional surveillance ($297 642), with an ICER <$50 000 in 96% of iterations. The p53-stratification strategy was associated with a 14% reduction in the overall endoscopy burden and a 59% increase in dysplasia detection. Conclusions: A surveillance strategy for BE based on abnormal p53 IHC is cost-effective relative to a conventional surveillance strategy and is likely to be associated with higher rates of dysplasia diagnosis.

JGH Open : An Open Access Journal Of Gastroenterology And Hepatology • April 29, 2024

Ciaran Judge, Abir Halder, Puraskar Pateria, Tzeng Khor, Niroshan Muwanwella, Marcus Chin, Krish Ragunath

Endoscopic submucosal dissection (ESD) has become the treatment of choice for many superficial gastric neoplasms. Clinical outcomes are increasingly comparable between Japanese and Western series; however, data are lacking on the validity of risk stratification tools in Western cohorts. We aimed to evaluate clinical outcomes, explore risk stratification, and compare our data with published Western series. We conducted a retrospective, observational cohort study in a single tertiary referral center over a 13-year period. Primary outcomes were rates of en bloc, complete (R0) and curative resection. Secondary outcomes included adverse events, recurrence, metachronous lesions, eCura grades, and ESGE criteria. A comparative analysis was performed with existing published series from Western centers. Totally 112 patients were included in the study cohort. 50.9% were male, 87.5% Caucasian, and median age was 75.5 years (IQR 14.3 years). Lesions were predominantly antral (36.6%) or body (35.7%); median size 20 mm (IQR 15 mm). Rates of en bloc, R0 resection, and curative resection were 96.4%, 89.3%, and 78.6% (identical between eCura and ESGE), respectively. Adverse events occurred in 5.8%, recurrence in 0%, and metachronous lesions in 9.9%. Our data compared favorably with a review existing Western series, which illustrates increasing adoption of ESD and stable outcomes over time. ESD represents a safe and effective method of treatment for gastric neoplasia in the Western setting. This study highlights the potential for excellent outcomes in a single center with a heterogeneous patient cohort and supports the use of eCura in guiding post procedural management.