Emerging molecules,tools,technology,and future of surgical knife in gastroenterology

The 21^(st) century has started with several innovations in the medical sciences,with wide applications in health care management.This development has taken in the field of medicines(newer drugs/molecules),various tools and technology which has completely changed the patient management including abdominal surgery.Surgery for abdominal diseases has moved from maximally invasive to minimally invasive(laparoscopic and robotic)surgery.Some of the newer medicines have its impact on need for surgical intervention.This article focuses on the development of these emerging molecules,tools,and technology and their impact on present surgical form and its future effects on the surgical intervention in gastroenterological diseases.

Will artificial intelligence reach any limit in gastroenterology?

Endoscopy is the cornerstone in the management of digestive diseases.Over the last few decades,technology has played an important role in the development of this field,helping endoscopists in better detecting and characterizing luminal lesions.However,despite ongoing advancements in endoscopic technology,the incidence of missed pre-neoplastic and neoplastic lesions remains high due to the operator-dependent nature of endoscopy and the challenging learning curve associated with new technologies.Artificial intelligence(AI),an operator-independent field,could be an invaluable solution.AI can serve as a“second observer”,enhancing the performance of endoscopists in detecting and characterizing luminal lesions.By utilizing deep learning(DL),an innovation within machine learning,AI automatically extracts input features from targeted endoscopic images.DL encompasses both computer-aided detection and computer-aided diagnosis,assisting endoscopists in reducing missed detection rates and predicting the histology of luminal digestive lesions.AI applications in clinical gastrointestinal diseases are continuously expanding and evolving the entire digestive tract.In all published studies,real-time AI assists endoscopists in improving the performance of non-expert gastroenterologists,bringing it to a level comparable to that of experts.The development of DL may be affected by selection biases.Studies have utilized different AI-assisted models,which are heterogeneous.In the future,algorithms need validation through large,randomized trials.Theoretically,AI has no limit to assist endoscopists in increasing the accuracy and the quality of endoscopic exams.However,practically,we still have a long way to go before standardizing our AI models to be accepted and applied by all gastroenterologists.

Ultrasound Pulse Elastometry: Assessment of One Year’s Practice in the Hepato-Gastroenterology Department of the Saint Camille Hospital in Ouagadougou

Aims: To review one year of ultrasound impulse elastometry in a hospital in Ouagadougou. Patients and Method: This is a retrospective descriptive study of data from one year’s use of impulse ultrasound elastometry. Ultrasound impulse elastometry was performed using the FibroScan® COMPACT 530. Fibrosis was considered significant when E (hepatic elasticity) ≥ 7.2 kPa (F2 fibrosis). The test was considered valid when the IQR/Median ratio ≤ 30% and there were at least 10 valid measurements. Results: A total of 1911 patients underwent FibroScan®. There were 1079 men, giving a sex ratio of 1.3. The mean age of the patients was 37.9 ± 12.2 years. The indication for FibroScan® was hepatitis B virus infection in 89% of cases. The validation criteria for FibroScan® were met in all patients. The mean value for elasticity was 7.9 kPa and for steatosis 212 dB/m. Fibrosis was non-significant in 75.5% of cases. More than half of our patients (56.7%) didn’t have steatosis, 24.8% had mild steatosis, 12.4% had moderate steatosis and 6.1% had severe steatosis. Conclusion: Ultrasound pulse elastometry plays an important role in monitoring chronic liver disease. It allows non-invasive diagnosis of hepatic fibrosis and steatosis. In our context, however, access to the test is limited by its availability only in large urban centers, and by its cost.

Charactistics of Anemia in Cirrhotics in the Gastroenterology Department at Brazzaville University Hospital

Objective: Study of the frequency of anemia, its characteristics and its relationship with different epidemiological, diagnostic and prognostic parameters of cirrhosis. Patients and methods: This was a retrospective descriptive study from January 2016 to December 2019 in the Gastroenterology and Internal Medicine department at the Brazzaville University Hospital. It concerned all cirrhotics hospitalized during the study period and presenting anemia. The epidemiological, diagnostic, and prognostic data studied were collected from medical records. The characteristics of anemia on the blood count were defined based on WHO values. The information collected was entered and processed with Excel 8.0 and EPI data 3.1 software. The Pearson chi2 test at the significance level ≤ 5% was used to compare the results. Results: We collected 102 files of cirrhotic patients during the study period. There were 63 men and 39 women, a sex ratio of 1.6. Among these patients, 77 presented anemia, i.e., a frequency of 75.5% with a male predominance (57.2%). Anemia increased without a significant relationship with age and was more severe in young female subjects (42.8%). The normochromic normocytic character was the most observed (52%). Anemia was more frequent in post-hepatitic cirrhosis, representing 67.5% of cases of anemia. It worsened during digestive bleeding, with the abundance of ascites and the severity of hepatic encephalopathy (p > 0.05). It was significantly associated with the drop in prothrombin level (63.6%), hypoalbuminemia (64.9%), and the Child-Pugh score (p < 0.05).

Scope and caveats:Artificial intelligence in gastroenterology

The use of Artificial intelligence(AI)has evolved from its mid-20th century origins to playing a pivotal tool in modern medicine.It leverages digital data and computational hardware for diverse applications,including diagnosis,prognosis,and treatment responses in gastrointestinal and hepatic conditions.AI has had an impact in diagnostic techniques,particularly endoscopy,ultrasound,and histopathology.AI encompasses machine learning,natural language processing,and robotics,with machine learning being central.This involves sophisticated algorithms capable of managing complex datasets,far surpassing traditional statistical methods.These algorithms,both supervised and unsupervised,are integral for interpreting large datasets.In liver diseases,AI's non-invasive diagnostic applications,particularly in non-alcoholic fatty liver disease,and its role in characterizing hepatic lesions is promising.AI aids in distinguishing between normal and cirrhotic livers and improves the accuracy of lesion characterization and prognostication of hepatocellular carcinoma.AI enhances lesion identification during endoscopy,showing potential in the diagnosis and management of early-stage esophageal carcinoma.In peptic ulcer disease,AI technologies influence patient management strategies.AI is useful in colonoscopy,particularly in detecting smaller colonic polyps.However,its applicability in nonacademic settings requires further validation.Addressing these issues is vital for harnessing the potential of AI.In conclusion,while AI offers transformative possibilities in gastroenterology,careful integration and balancing of technical possibilities with ethical and practical application,is essential for optimal use.

This year's Nobel Prize to gastroenterology:Robin Warren and Barry Marshall awarded for their discovery of Helicobacter pylori as pathogen in the gastrointestinal tract

TO THE EDITORPeptic ulcer disease is a major health care concern in the society today, in view of personal suffering as well as economical health care costs.

Magnifying endoscopy in upper gastroenterology for assessing lesions before completing endoscopic removal

Any prognosis of gastrointestinal (GI) cancer is closely related to the stage of the disease at diagnosis.Endoscopic submucosal dissection (ESD) and en bloc endoscopic mucosal resection (EMR) have been performed as curative treatments for many early-stage GI lesions in recent years.The technologies have been widely accepted in many Asian countries because they are minimally invasive and supply thorough histopathologic evaluation of the specimens.However,before engaging in endoscopic therapy,an accurate diagnosis is a precondition to effecting the complete cure of the underlying malignancy or carcinoma in situ.For the past few years,many new types of endoscopic techniques,including magnifying endoscopy with narrow-band imaging (MENBI),have emerged in many countries because these methods provide a strong indication of early lesions and are very useful in determining treatment options before ESD or EMR.However,to date,there is no comparable classification equivalent to "Kudo's Pit Pattern Classification in the colon",for the upper GI,there is still no clear internationally accepted classification system of magnifying endoscopy.Therefore,in order to help unify some viewpoints,here we will review the defining optical imaging characteristics and the current representative classifications of microvascular and microsurface patterns in the upper GI tract under ME-NBI,describe the accurate relationship between them and the pathological diagnosis,and their clinical applications prior to ESD or en bloc EMR.We will also discuss assessing the differentiation and depth of invasion,defying the lateral spread of involvement and targeting biopsy in real time.

Endoscopic ultrasound in gastroenterology:From diagnosis to therapeutic implications

Since its advent in 1980,the scope of endoscopic ultrasound(EUS)has grown to include a wide range of indications,and it is now being incorporated as an integral part of everyday practice in the field of gastroenterology.Its use is extending from an adjuvant imaging aid to utilization as a therapeutic tool for various gastrointestinal disorders.EUS was first used to visualize remote organs,such as the pancreas and abdominal lymph nodes.When fine needle aspiration was introduced,the indications for EUS expanded to include tissue sampling for diagnostic purposes.At the same time,the needle can be used to convey a potential therapy to the internal organs,allowing access to remote sites.In this review,we aim to highlight the expanding spectrum of EUS indications and uses in the field of gastroenterology.

Artificial intelligence in gastroenterology: A state-of-the-art review

The development of artificial intelligence(AI)has increased dramatically in the last 20 years,with clinical applications progressively being explored for most of the medical specialties.The field of gastroenterology and hepatology,substantially reliant on vast amounts of imaging studies,is not an exception.The clinical applications of AI systems in this field include the identification of premalignant or malignant lesions(e.g.,identification of dysplasia or esophageal adenocarcinoma in Barrett’s esophagus,pancreatic malignancies),detection of lesions(e.g.,polyp identification and classification,small-bowel bleeding lesion on capsule endoscopy,pancreatic cystic lesions),development of objective scoring systems for risk stratification,predicting disease prognosis or treatment response[e.g.,determining survival in patients post-resection of hepatocellular carcinoma),determining which patients with inflammatory bowel disease(IBD)will benefit from biologic therapy],or evaluation of metrics such as bowel preparation score or quality of endoscopic examination.The objective of this comprehensive review is to analyze the available AI-related studies pertaining to the entirety of the gastrointestinal tract,including the upper,middle and lower tracts;IBD;the hepatobiliary system;and the pancreas,discussing the findings and clinical applications,as well as outlining the current limitations and future directions in this field.

Evolution of gastroenterology training

There have been rapid developments in gastroenterology(GE)over the last decade.Up until the late 1980s,GE-training was incorporated in Internal Medicine training.The introduction of endoscopy has necessitated the need for additional training.Around the world different national boards have developed their own curricula which will be discussed in this paper. Emphasis will be placed on the curriculum recently introduced in The Netherlands.The internal medicine component has become a two-year requirement (Common Trunk)and the duration of training in GE has been extended to four years.Because of the growing complexity of GE,there are now four subspecialties:Interventional Endoscopy,Neuromotility, Oncology and Hepatology that trainees can choose from.These subspecialties each have predefined specific requirements.The World Gastroenterology Organization has drawn up a standard curriculum which can be of help to the boards in different countries. The curriculum emphasizes the knowledge and skill components.The curriculum also defines the training recommendations,the requirements of training facilities and competence evaluation of fellows and facilities,while less is said about research,finance and the number of gastroenterologists required.In the coming decades the curriculum will need to be revised continuously.Personalization of the curriculum will be the next challenge for the years to come.

Gastroenterology training in private hospitals:India vs South Africa

In South Africa,nurses and doctors are emigrating in significant numbers. Job satisfaction,safety and ensuring career progression are important in retaining doctors to make a career in Republic of South Africa (RSA). Due to budgetary constraints many hospitals have not been upgraded. Coming home after overseas training seems difficult. In RSA it takes a minimum of 13 years for a young specialist to become registered and 15 years for subspecialists. Career progression,creating more specialist trainees in public and private hospitals and shortening the period of professional training are potential solutions to the problem. India,which has a population of more than 1 billion people,is struggling with similar problems. For the past 10-15 years,private hospitals have assisted in manpower development for medical specialist and subspecialist careers. Currently their private sector trains 60% of their recognised (sub)specialities fellows. A national task force for specialist training in RSA should be instituted. It should discuss,based on the current status and projected specialist and subspecialist personnel requirements,thefuture structure and logistics of training needs. This is required in all subspecialities including gastroenterology,as has been done in India. It is hoped that as a consequence well-trained doctors,similar to those in India,might move to provincial hospitals in rural areas,upgrading the medical services and keeping medical power in South Africa. South Africa should become a model for Sub-Saharan Africa,as India already is for South-East Asia.

Behavioral gastroenterology: An emerging system and new frontier of action

Behavioral gastroenterology is a new interdisciplinary science that explores the influence of unhealthy lifestyles and psychological factors on the digestive system and addresses the prevention,diagnosis,treatment,and rehabilitation of digestive diseases. Moreover,the concept of whole-course intervention with a focus on disease prevention and a new model of integrated therapy based on alterations of lifestyle and psychology are being gradually established. This paradigm may substantively impact the prevention and treatment of digestive diseases.

Digestive oncologist in the gastroenterology training curriculum

Until the late 1980s, gastroenterology (GE) was considered a subspecialty of Internal Medicine. Today, GE also incorporates Hepatology. However, Digestive Oncology training is poorly defined in the Hepatogastroenterology (HGE)-curriculum. Therefore, a Digestive Oncology curriculum should be developed and this document might be a starting point for such a curriculum. HGE-specialists are increasingly resisting the paradigm in which they play only a diagnostic and technical role in the management of digestive tumors. We suggest minimum endpoints in the standard HGE-curriculum for oncology, and recommend a focus year in the Netherlands for Digestive Oncology in the HGE-curriculum. To produce welltrained digestive oncologists, an advanced Digestive Oncology training program with specific qualifications in Digestive Oncology (2 years) has been developed. The schedule in Belgium includes a period of at least 6 mo to be spent in a medical oncology department. The goal ofthese programs remains the production of well-trained digestive oncologists. HGE specialists are part of the multidisciplinary oncological teams, and some have been administering chemotherapy in their countries for years. In this article, we provide a road map for the organization of a proper training in Digestive Oncology. We hope that the World Gastroenterology Organisation and other (inter)national societies will support the necessary certifications for this specific training in the HGE-curriculum.

Gastroenterology service in a teaching hospital in rural New Zealand, 1991-2003

AIM: To retrospectively collect inpatient and outpatient data and to assess the use of endoscopic procedures during the years 1991, 1997 and 2003 to analyse for trends. METHODS: This retrospective survey was conducted in a University-associated Gastroenterology Unit offering secondary and tertiary health care services for a population of approximately 182 000 people in Southern New Zealand. Data collected included patient contacts (inand outpatients), gastroscopic and colonoscopic investigations. RESULTS: We observed a significant increase in the absolute numbers of patient contacts over the years (1991: 2308 vs 1997: 2022 vs 2003: 2783, P < 0.0001) with inflammatory bowel disease, other diseases of the colon, anus and rectum and iron studies related disorders decreasing significantly but liver disease and constipation increasing linearly over time. The use of endoscopy services remained relatively stable but colonoscopic investigations for a positive family history of colorectal cancer increased significantly while more gastroscopies were performed for unexplained anaemia. CONCLUSION: The whole spectrum of gastroenterology contacts was studied. A substantial proportion of colonoscopies and outpatient consultations were undertaken to screen for colorectal cancer. This proportion is likely to grow further. Our fi ndings have implications for the recruitment and training of the next generation of gastroenterologists.

Subtle skills: Using objective structured clinical examinations to assess gastroenterology fellow performance in system based practice milestones

BACKGROUND System based practice(SBP) milestones require trainees to effectively navigate the larger health care system for optimal patient care. In gastroenterology training programs, the assessment of SBP is difficult due to high volume, high acuity inpatient care, as well as inconsistent direct supervision. Nevertheless,structured assessment is required for training programs. We hypothesized that objective structured clinical examination(OSCE) would be an effective tool for assessment of SBP.AIM To develop a novel method for SBP milestone assessment of gastroenterology fellows using the OSCE.METHODS For this observational study, we created 4 OSCE stations: Counseling an impaired colleague, handoff after overnight call, a feeding tube placement discussion, and giving feedback to a medical student on a progress note. Twentysix first year fellows from 7 programs participated. All fellows encountered identical case presentations. Checklists were completed by trained standardized patients who interacted with each fellow participant. A report with individual and composite scores was generated and forwarded to program directors to utilize in formative assessment. Fellows also received immediate feedback from a faculty observer and completed a post-session program evaluation survey.RESULTS Survey response rate was 100%. The average composite score across SBP milestones for all cases were 6.22(SBP1), 4.34(SBP2), 3.35(SBP3), and 6.42(SBP4)out of 9. The lowest composite score was in SBP 3, which asks fellows to advocate for cost effective care. This highest score was in patient care 2, which asks fellows to develop comprehensive management plans. Discrepancies were identified between the fellows’ perceived performance in their self-assessments and Standardized Patient checklist evaluations for each case. Eighty-seven percent of fellows agreed that OSCEs are an important component of their clinical training,and 83% stated that the cases were similar to actual clinical encounters. All participating fellows stated that the immediate feedback was "very useful." One hundred percent of the fellows stated they would incorporate OSCE learning into their clinical practice.CONCLUSION OSCEs may be used for standardized evaluation of SBP milestones. Trainees scored lower on SBP milestones than other more concrete milestones. Training programs should consider OSCEs for assessment of SBP.

COVID-19:Effect on gastroenterology and hepatology service provision and training:Lessons learnt and planning for the future

In late 2019,reports arose of a new respiratory disease in China,identified as a novel coronavirus,severe acute respiratory syndrome coronavirus 2.The World Health Organisation named the disease caused by the virus‘coronavirus disease 2019(COVID-19)’.It was declared a pandemic in early 2020,after the disease rapidly spread across the world.COVID-19 has not only resulted in substantial morbidity and mortality but also significantly impacted healthcare service provision and training across all medical specialties with gastroenterology and Hepatology services being no exception.Internationally,most,if not all‘nonurgent’services have been placed on hold during surges of infections.As a result there have been delayed diagnoses,procedures,and surgeries which will undoubtedly result in increased morbidity and mortality.Outpatient services have been converted to remote consultations where possible in many countries.Trainees have been redeployed to help care for COVID-19 patients in other settings,resulting in disruption to their training-particularly endoscopy and outpatient clinics.This has led to significant anxiety amongst trainees,and risks prolongation of training.It is of the utmost importance to develop strategies that continue to support COVID-19-related service provision,whilst also supporting existing and future gastroenterology and Hepatology services and training.Changes to healthcare provision during the pandemic have generated new and improved frameworks of service and training delivery,which can be adopted in the post-COVID-19 world,leading to enhanced patient care.

Economic evaluations in gastroenterology in Brazil: A systematic review

AIM: To systematically review economic evaluations in gastroenterology, relating to Brazil, published between 1980 and 2013. METHODS: We selected full and partial economic evaluations from among those retrieved by searching the following databases: MEDLINE(PubM ed); Excerpta Medica; the Latin American and Caribbean Health Sciences Literature database; the Scientific Electronic Library Online; the database of the Centre for Reviews and Dissemination; the National Health Service(NHS) Economic Evaluation Database; the NHS Health Technology Assessment database; the Health Economics database of the Brazilian Virtual Library of Health; Scopus; Web of Science; and the Brazilian Network for the Evaluation of Health Technologies. Two researchers, working independently, selected the studies and extracted the data. RESULTS: We ide nt if ie d 535 he alt h e c onomic evaluations relating to Brazil and published in the 1980-2013 period. Of those 535 articles, only 40 dealt with gastroenterology. Full and partial economic evaluations respectively accounted for 23(57.5%) and 17(42.5%) of the 40 studies included. Among the 23 full economic evaluations, there were 11 cost-utility analyses, seven cost-effectiveness analyses, four costconsequence analyses, and one cost-minimization analysis. Of the 40 studies, 25(62.5%) evaluated medications; 7(17.5%) evaluated procedures; and 3(7.5%) evaluated equipment. Most(55%) of the studies were related to viral hepatitis, and most(63.4%) were published after 2010. Other topics included gastrointestinal cancer, liver transplantation, digestive diseases and hernias. Over the 33-year period examined, the number of such economic evaluations relating to Brazil, especially of those evaluating medications for the treatment of hepatitis, increased considerably. CONCLUSION: Further studies are needed in order to ensure that expenditures on health care in Brazil are made as fairly and efficiently as possible.

Emerging artificial intelligence applications in gastroenterology: A review of the literature

Artificial intelligence(AI)allows machines to provide disruptive value in several industries and applications.Applications of AI techniques,specifically machine learning and more recently deep learning,are arising in gastroenterology.Computer-aided diagnosis for upper gastrointestinal endoscopy has growing attention for automated and accurate identification of dysplasia in Barrett’s esophagus,as well as for the detection of early gastric cancers(GCs),therefore preventing esophageal and gastric malignancies.Besides,convoluted neural network technology can accurately assess Helicobacter pylori(H.pylori)infection during standard endoscopy without the need for biopsies,thus,reducing gastric cancer risk.AI can potentially be applied during colonoscopy to automatically discover colorectal polyps and differentiate between neoplastic and nonneoplastic ones,with the possible ability to improve adenoma detection rate,which changes broadly among endoscopists performing screening colonoscopies.In addition,AI permits to establish the feasibility of curative endoscopic resection of large colonic lesions based on the pit pattern characteristics.The aim of this review is to analyze current evidence from the literature,supporting recent technologies of AI both in upper and lower gastrointestinal diseases,including Barrett's esophagus,GC,H.pylori infection,colonic polyps and colon cancer.

Role of Orvosi Hetilap in the development of Hungarian gastroenterology

AIM:To analyze the contribution of Orvosi Hetilap(Hungarian Medical Journal) to the field of gastroenterology.METHODS:All issues of the journal between 1857 and 2008 and identified original articles and reviews dealing with gastroenterology were reviewed.The rate of publications,the thematic distribution and foreign sources of knowledge were assessed.The dates that major achievements in gastroenterology were introduced in Hungary were compared to those dates in Western medicine.RESULTS:A total of 4799 original/research articles on gastroenterology were published,which represents 11.1% of the total publications.Thematic rankings showed that liver and biliary diseases represented 20.36% of the total,followed by gastric diseases(9.35%) and surgery(8.77%).A total of 268 foreign journals were reviewed:50.9% were German,30.4% English,12.1% French and only 6.6% were in other languages.The major achievements of gastroenterology were introduced with varying delays compared to Western countries.CONCLUSION:Orvosi Hetilap has made a large contribution to the development of Hungarian gastroenterology.The high proportion of gastroenterology studies underlines the importance of digestive diseases in public health.

Clinical nutrition in the hepatogastroenterology curriculum

Gastroenterology(GE) used to be considered a subspecialty of internal medicine. Today, GE is generally recognized as a wide-ranging specialty incorporating capacities, such as hepatology, oncology and interventional endoscopy, necessitating GEexpert differentiation. Although the European Board of Gastroenterology and Hepatology has defined specific expertise areas in Advanced endoscopy, hepatology, digestive oncology and clinical nutrition, training for the latter topic is lacking in the current hepatogastroenterology(HGE) curriculum. Given its relevance for HGE practice, and being at the core of gastrointestinal functioning, there is an obvious need for training in nutrition and related issues including the treatment of disease-related malnutrition and obesity and its associated metabolic derangements. This document aims to be a starting point for the integration of nutritional expertise in the HGE curriculum, allowing a central role in the management of malnutrition and obesity. We suggest minimum endpoints for nutritional knowledge and expertise in the standard curriculum and recommend a focus period of training in nutrition issues in order to produce well-trained HGE specialists. This article provides a road map for the organization of such a training program. We would highly welcome the World Gastroenterology Organisation, the European Board of Gastroenterology and Hepatology, the American Gastroenterology Association and other(inter)national Gastroenterology societies support the necessary certifications for this item in the HGE-curriculum.