Introduction

Neuroendocrine tumors (NETs) are heterogeneous neoplasms originating from neuroendocrine cells, predominantly located in the gastrointestinal tract and pancreas. While surgical resection remains the primary curative intervention, a significant number of patients are ineligible for surgery due to comorbidities or the anatomical positioning of the tumor. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has emerged as a minimally invasive alternative; however, the extant evidence is predominantly derived from small-scale case studies.

Aims & Methods

This multicenter study aims to comprehensively evaluate the efficacy, safety, and technical considerations of EUS-RFA in the management of NETs. A retrospective analysis was conducted on 45 patients with histologically confirmed neuroendocrine tumors (NETs) from five countries: Costa Rica, Egypt, India, Palestine, and Romania. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) was performed using a standardized 19-gauge RFA needle equipped with a 1 cm active-tip electrode. The primary outcomes assessed were treatment success, categorized as complete, partial, or failure. Secondary outcomes included the evaluation of complications and their correlations with tumor characteristics (such as grade, location, and histology), technical parameters (including power settings and ablation duration), and clinical factors. Statistical analyses were conducted using SPSS, employing Chi-square and Kruskal-Wallis tests.

Results

The cohort consisted of 53.3% females, with a mean age of 47.87 years. The overall complete ablation rate was 75.6%, with higher success rates observed for higher-grade tumors (G2/G3: 100% vs. G1: 80.8%). Tumor location significantly influenced outcomes, with pancreatic tail/neck lesions achieving 100% complete ablation compared to 58.8% for head lesions. Power settings of 35W, 40W, and 60W yielded 100% success, whereas 50W and 30W demonstrated lower efficacy (72.2% and 62.5%, respectively). Ablation duration tended to be longer in successful cases (mean 16.36 seconds) compared to failures (4.50 seconds). Insulinomas exhibited an 89.7% complete ablation rate, surpassing non-functioning NETs (50%). Complications were minimal, underscoring the procedure's safety.

Conclusion

Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) represents a safe and efficacious minimally invasive approach for the treatment of neuroendocrine tumors (NETs), particularly in patients who present a high surgical risk. The success of this technique is contingent upon the biological characteristics of the tumor, anatomical considerations, and the precision of the procedure. Future research should aim to standardize protocols, integrate advanced imaging techniques, and investigate combination therapies to further enhance this promising intervention.

References

1. Oronsky B, Ma PC, Morgensztern D, Carter CA. Nothing But NET: A Review of Neuroendocrine Tumors and Carcinomas. Neoplasia 2017; 19: 991–1002. [DOI: 10.1016/j.neo.2017.09.002]
2. Verma SK, Khare R, Singh D. Current perspectives on neuroendocrine tumors. hLife 2024; 2: 563–575. [DOI: 10.1016/j.hlife.2024.07.006]
3. Modlin IM, Oberg K, Chung DC, Jensen RT, de Herder WW, Thakker RV, Caplin M, Delle Fave G, Kaltsas GA, Krenning EP, Moss SF, Nilsson O, Rindi G, Salazar R, Ruszniewski P, Sundin A. Gastroenteropancreatic neuroendocrine tumours. The Lancet Oncology 2008; 9: 61–72. [DOI: 10.1016/S1470-2045(07)70410-2]

Introduction

Contemporary studies suggest there are racial disparities in the outcomes of acute presentations. This study aimed to investigate the impact of sex and race on the management and outcomes of patients presenting with upper gastrointestinal bleeding (UGIB).

Aims & Methods

Using International Classification of Diseases 10th Revision Codes, all adults >18 admitted from 2016–2020 with a discharge diagnosis of UGIB were extracted from the National Inpatient Sample.

Results

In over 900,000 hospitalisations for UGIB, 69.4%, 14.1%, 9.6%, 3.6%, 0.9% and 2.4% were for admissions in white, black, Hispanic, Asian/pacific islander, native American and ‘other’ patients respectively. Comorbidity burden varied between racial groups (p<0.001). White patients had higher crude rates of endoscopy, and comparable rates of surgery or interventional radiology to control blood loss, in comparison to other racial groups. Adjusted analysis revealed that black and Asian/pacific islander racial group patients had lower odds of in-hospital all cause mortality compared to white patients, but ‘other’ racial group patients had higher odds of mortality (p<0.001). There was no difference for Hispanic or native American patients. For non-variceal bleeding, these outcomes persisted. However, for variceal bleeds, there were no significant differences in outcomes between each racial group.

Conclusion

There are racial disparities in the management and outcomes of admissions for UGIB. These difference persist despite the aetiology of bleeding. Underlying reasons for differences in outcomes must be investigated to ensure improved outcomes across high-risk patient groups.

Introduction

Upper gastrointestinal bleeding (UGIB) is a major cause of mortality in the United States (US). This study aimed to investigate the contemporary trends in the management and outcomes of these patients as well as factors associated with in-hospital mortality, using national data.

Aims & Methods

The US National Inpatient Sample was queried from 2016-2020. Using International Classification of Diseases 10th Revision Codes, all adults >18 admitted with a principal discharge diagnosis of UGIB were extracted along with data about demographics, management and outcomes. Categorical variables were compared using chi-squared and expressed as percentages (%). Logistic regression was performed, adjusting for variables associated with adverse outcomes and reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Data were considered significant if p<0.001.

Results

There were 918,925 hospitalizations for UGIB in the study period. Variceal bleeding occurred in 36,050 (3.9%) of admissions. Endoscopy was performed in 451,450 (49.1%) of admissions, with 10,160 (1.1%) of admissions and 9,355 (1.0%) of admissions requiring interventional radiology and gastrointestinal surgery to control blood loss respectively. The crude rate of all-cause in-hospital mortality was 1.9%. Factors associated with death included variceal bleed (aOR 2.84 CI 2.67-3.02), age (aOR 1.03 CI 1.03-1.03), history of cancer (aOR 2.45 CI 2.35-2.56), ulcer disease (aOR 1.44 CI 1.39-1.49), chronic renal failure (aOR 1.34 CI 1.29-1.37), chronic obstructive pulmonary disease (aOR 1.29 CI 1.24-1.34), receipt of endoscopy (aOR 1.33 CI 1.29-1.38), surgery (aOR 3.92 CI 3.63-4.24) and interventional radiology (aOR 3.33 CI 3.09-3.58).

Conclusion

UGIB remains a significant cause of hospitalisation in the US. Knowledge of the contemporary trends and outcomes of this patient group is important to improve management in this at-risk patient group.

Introduction

The prevalence of adenoma in patients with positive fecal immunochemical tests (FIT) is shown to be higher. Increased adenoma detection and removal during colonoscopy have been shown to prevent CRC and interval cancers. However, there is considerable variation in the adenoma detection rate (ADR) among colonoscopies performed for FIT. We hypothesize that the ability of dye-based chromoendoscopy to stain the colorectal lesion and their borders and increase their contrast against the normal colorectal mucosa would enhance the detection of adenoma and non-polypoid colorectal neoplasms (NPCRN) in patients undergoing FIT positive colonoscopy. In this randomized control trial, we aim to compare the effectiveness of pan-colonic indigo carmine chromoendoscopy (PCC) to high-definition white light colonoscopy (WLC) in individuals undergoing colonoscopy for positive FIT test.

Aims & Methods

Patients undergoing colonoscopy after a FIT positive test were randomized 1:1 to undergo PCC or WLC. The study was conducted between January 2021 to May 2023 at the Singapore General Hospital, Singapore. Colonoscopy was performed by general and advanced endoscopists, and all received training on PCC before the study. The primary outcome was ADR between the two groups. The secondary outcomes were advanced adenoma detection rate (AADR), NPCRN detection rate, sessile serrated lesion detection rate (SSLDR), and withdrawal time between the groups. We used the two-tailed Mann–Whitney U test and Chi-squared statistics for comparison. The ethics committee approved the study, and it was registered with clinicaltrials.gov (NCT04512612)

Results

We recruited 256 patients (PCC-128; WLC-128). The mean age of the entire cohort was 66 + 8.4 years. The mean ADR was comparable between PCC and WLC (70.3% vs. 64.8%, p-0.350). Likewise, the AADR (19.5% vs. 14.8%, p-0.320], and SSLDR (6.25% vs. 1.56%, p-0.102] were similar between the two groups. We found PCC detected more diminutive adenomas (0.97% vs. 0.58%, p-0.025] and NPCRN per colonoscopy (0.35% vs. 0.17%, p-0.028). The mean withdrawal time was longer with PCC compared to WLC (13.3 min vs. 10.2 min, p-0.001). General and advanced endoscopists had no difference in performance measures for APC and NPCRN per colonoscopy.

Conclusion

The ADR in FIT-positive colonoscopy is higher, and both PCC and WLC yielded comparable results. PCC merits consideration because of its increased ability to detect NPCRNs, which are precursors for interval cancer.

Introduction

Thyroidectomy is one of the most common surgical procedures worldwide, yet its potential effects on esophageal function remain inadequately characterized. While post-thyroidectomy issues such as voice changes have been well-documented, alterations in esophageal motility following this procedure have received limited attention in scientific literature.

Aims & Methods

This study aims to evaluate the impact of thyroidectomy on esophageal motility parameters using High-resolution manometry (HRM), with particular attention to upper esophageal sphincter (UES) function. Seventeen patients (11 females), who were to undergo total thyroidectomy or hemithyroidectomy, were prospectively recruited between the months of February and May 2023. Ten of them had goiters, while seven had thyroid nodules. Exclusion criteria were having an age under 30 or over 70 years old, having to also undergo a parathyroid surgery and taking medications that could alter the esophageal sphincter. All of them underwent a pre-operative HRM and a second one thirty days after surgery. HRM were performed according to the Chicago Classification 4.0 and the data were analyzed using the online analysis platform “Swallow Gateway”. Gastrointestinal (GI) symptoms were assessed using a standardized questionnaire, before the first and the second HRM. No after procedural complication was reported.

Results

UES function significatively changed after thyroidectomy, as it is shown by HRM metrics such as Pharyngeal Contractile Integral (CI), Velopharyngeal CI, Hypopharyngeal CI, UES-CI, UES Integrated Relaxation Pressure (UES-IRP), Post-Deglutitive UES CI, Proximal Contractile Integral (PCI), which all significatively decreased (p < 0.05) at the HRM performed after surgery. Compared to Swallow Gateway normal values, there was an important increase of pathological HRM metrics after thyroidectomy. No significant HRM difference was found between the two categories of patients (goiter and thyroid nodules) and no significant correlation was registered between GI symptoms pre- and post-surgery and between GI symptoms and HRM metrics.

Conclusion

Thyroidectomy may significantly affect esophageal motility, especially the function of the upper esophageal sphincter. This finding could be useful in the diagnostic and therapeutic pathway of these patients, although further and larger studies are required to confirm this result.

Introduction

Primary biliary cholangitis (PBC) is often associated with extrahepatic autoimmune diseases (EAIDs) such as Sjögren’s syndrome, autoimmune thyroiditis, and connective tissue disorders. While this association suggests a shared immunological predisposition, its effect on disease prognosis remains unclear.

Aims & Methods

This retrospective study included 69 patients diagnosed with PBC, excluding those with overlap syndromes involving autoimmune hepatitis. Patients were divided into two groups: isolated PBC (n = 35) and PBC associated with EAIDs (n = 34). The two groups were compared based on clinical, immunological, elastometric characteristics, disease progression, and prognostic scores (Paris I, Paris II, Rotterdam, Barcelona, Rochester, GLOBE, UK-PBC). Statistical analysis was conducted using appropriate tests, with a significance threshold set at p < 0.05.

Results

The average age at diagnosis was 55.6 years. The disease was initially suspected based on functional symptoms in 39% of cases (fatigue, pruritus, arthralgia), biological cholestasis in 33.3%, and decompensated cirrhosis in 20.3%. The most common associated autoimmune diseases were Sjögren’s syndrome (17.4%), thyroid disorders (13%), and systemic lupus erythematosus (10.1%). All patients received treatment with ursodeoxycholic acid at 13-15 mg/kg/day. No significant differences were found between the two groups regarding functional symptoms, biological markers (bilirubin, albumin, prothrombin time), autoantibodies (AMA, Anti-GP210, anti-SP100, anti-PML), non-invasive fibrosis scores (Fib4, Fibroindex, Fibroscan, S-index), or hepatic complications (HDH, cirrhosis, hepatic encephalopathy, liver-related death). Prognostic scores were also comparable between both groups: Paris I (p = 0.468), Paris II (p = 0.519), GLOBE score (p = 0.6), UK-PBC (p = 0.49), Rotterdam (p = 0.897), Barcelona (p = 0.181), Rochester (p = 0.727).

Conclusion

The presence of extrahepatic autoimmune diseases in PBC does not appear to affect the clinical, biological, or prognostic profiles of patients. Despite their frequency, these comorbidities do not seem to influence the progression of PBC.

Disclosure

None.

Clinical Case Summary

A 58 year-old woman was admitted for an elective rectosigmoidectomy after two previous uncomplicated diverticulitis episodes. On the third postoperative day, her clinical status deteriorated, and an abdominal CT scan revealed an anastomotic leak, leading to a new surgery and confection of a protective ileostomy. Her condition improved progressively, and she was discharged 10 days after. However, the patient came back to the emergency one week later with abdominal pain, fatigue, and refractory nausea and vomiting, in addition to acute renal failure with severe hyponatremia and hyperkalemia. Because her daily ileostomy’s output reached about 2 liters/day, she was started on high dose opioids and loperamide to decrease the stoma’s output, as well as replacement fluid therapy, improving quickly within 24 to 48 hours. She was discharged in 5 days.
Despite the adequate control of the ileostomy’s output, her second readmission occurred 12 days later, showing the same clinical and laboratorial patterns. Considering she had a typical profile for adrenal insufficiency, fludrocortisone was associated with the antimotility agents, showing a significant improvement within hours. Nonetheless, she discontinued fludrocortisone on her own, and a third readmission occurred in 10. One more time, clinical and laboratorial characteristics were the same, with rapid improvement in the short term. An extensive investigation was conducted, revealing an aldosterone level more than 10 times higher than upper limit of normal, with normal renin levels and an adrenocorticotropic hormone in the lower limit of normal. These paradoxical findings were reinforced with a low urine and high ileostomy sodium dosages, and a diagnosis of a type 3 pseudohypoaldosteronism was made. Definitive treatment with intestinal transit’s reconstruction was performed, with complete resolution.

References

1. Carl C, Dinkelbach L, Mohr J, Perez R, Vera Lopez T, Fricke-Otto S, Niehues T. Case report: Life threatening hyponatremia in infants with urinary tract infections: two cases of type III pseudohypoaldosteronism and review of the literature. Front Pediatr. 2024 Jan 5;11:1233205. doi: 10.3389/fped.2023.1233205. PMID: 38250595; PMCID: PMC10797885.
2. Amir Babiker, Haya Aldabas, Shahad Alanazi, Bashayer Alahmadi, Waleed Tamimi, Mohsen Al Atawi, Fahad Aljuraibah, Angham Almutair. Pseudohypoaldosteronism: A challenging diagnosis with management pitfalls - Case series. Journal of Clinical and Translational Endocrinology: Case Reports, Volume 32, 2024, 100172. ISSN 2214-6245
3. Stojanović, V., Spasojević, S., Radovanović, T., & Doronjski, A. (2017). Pseudohypoaldosteronism: report of three cases. Journal of Endocrinology, Metabolism and Diabetes of South Africa, 22(2), 17–20. https://doi.org/10.1080/16089677.2017.1335532
4. Nakasone, Ruka et al. Three cases of pseudohypoaldosteronism following ileostomy in preterm infants. Pediatrics & Neonatology, Volume 62, Issue 1, 119 - 121