Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a pioneering procedure in the management of pancreatobiliary diseases. However, access to the common bile duct is not always easy, even in expert hands, with a failure rate ranging between 5% and 10%. A second attempt or alternative cannulation techniques are often required before considering surgery.

Aims & Methods

The aim of this study was to assess the ERCP failure rate in a tertiary care center.
This was a retrospective, descriptive, and analytical study conducted in a hepatogastroenterology department. It included patients who underwent ERCP with failed bile
duct cannulation over a 6-year period.

Results

Out of 801 ERCP procedures performed, 14 failures (1.7%) were recorded. Among these patients, 28.6% (4 patients) underwent a second ERCP attempt, with one of them being
successful. The indications for ERCP were: pancreatic head tumor in 43% of cases (6), common bile ductstones in 36% (5), cholangiocarcinoma in 14% (2), and bile duct trauma in 7% (1). The techniques used for cannulation were primarily guidewire-assisted cannulation in 79% of cases (11) and precut sphincterotomy in 21% (3). 8 patients (62%) had surgical drainage and 5 patients (38%) underwent endoscopic ultrasound-guided drainage after ERCP failure.

Conclusion

Our study demonstrates a low ERCP failure rate, comparable to that of international centers. Surgical intervention was more common early in the experience, prior to the introduction of endoscopic ultrasound-guided drainage in our practice.

Introduction

While the clinical trial (JCOG1009/1010) evaluating the efficacy and safety of endoscopic submucosal dissection (ESD) for intramucosal (T1a(M)) undifferentiated early gastric cancer (UD-EGC) of the predominant type measuring <2 cm not associated with ulceration showed a favorable 5-year survival outcome (99.3% (95% confidence interval: 97.1-99.8 )), the 10-year prognosis is still uncertain. We have followed the patients for 10 years.

Aims & Methods

Main eligibility criteria were endoscopically diagnosed cT1a/N0/M0, single primary lesion, size ≤2 cm, no ulceration, and histological components of undifferentiated adenocarcinoma in biopsy. Based on the histologic findings after ESD, additional gastrectomy was indicated if the histopathologic examination did not meet the criteria for curative resection. The primary endpoint was 5-year overall survival (OS) of the undifferentiated-predominant type group, and 10-years follow-up of patients was planned.

Results

Of a total of 346 patients enrolled between February 2011 and May 2013 from 49 institutions, 337 were eligible and all eligible patients underwent ESD. Histopathologic findings of the resected specimens showed undifferentiated predominant cancer in 275 patients while one patient could not be evaluated due to emergent surgery for a perforation during ESD. Of the 275 patients, 195 whose ESD was judged to result in a curative resection were followed up without additional treatment, and 73 of the remaining 79 patients whose ESD was judged to result in a non-curative resection received additional gastrectomy. Among the 275 patients with UD-EGC, one patient experienced a metastatic recurrence 3,034 days after ESD. The 10-year OS and relapse-free survival (RFS) of patients with undifferentiated-predominant type were 96.2% (95% confidence interval: 93.1-97.9) and 95.7% (95% confidence interval: 92.4-97.6), respectively, while the 10-year OS and RFS for all 346 enrolled patients were 95.1 % and 94.7 %, respectively.

Conclusion

ESD for UD-EGC with tumor size of 2 cm or less is the standard treatment, with excellent 10-year survival results as well as in the 5-year period.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is essential for managing liver transplant complications. Dilations, stent placement, and stone removal are typically performed during these procedures. Post-ERCP pancreatitis (PEP) occurs in 5-8% of the general population, but its incidence in liver transplant (LT) patients remains undefined. This special group exhibits characteristics that warrant dedicated analysis (immunosuppression, altered anatomy and complexity of ERCP). Conflicting data exist in literature and risk factors in LT patients are poorly understood. This study aims to clarify the incidence of PEP in this population and identify specific risk factors for its development.

Aims & Methods

A total of 189 patients (271 ERCPs) were analyzed between 2022 and 2024. The first part of the study included 75 LT recipients; the second part evaluated the general population composed of 75 LT and 114 non LT. Data collected included demographics, medical history, procedural details and PEP occurrence. Statistical analysis comprise univariate and multivariate models, adjusting for repeated procedures on the same patient when necessary.

Results

The incidence of PEP in LT patients is significantly higher (21.3%) compared to non-LT patients (8.7%). Liver transplantation was a notable risk factor for PEP (p=0.014), with a trend in multivariate analysis (OR=2.29; p=0.078). Difficult cannulation strongly correlated with PEP in both groups, particularly in LT patients (OR=4.86; p=0.013). In LT recipients, female sex (OR=3.11; p=0.094), shorter transplantation-to-ERCP interval, and dual immunosuppressive therapy showed a potential risk association. Conversely, prior biliary stent placement reduced PEP risk (OR=0.131; p=0.001).

Conclusion

LT recipients have a higher PEP risk due to procedural and patient-specific factors. Female sex plays a greater role than in the general population, while dual immunosuppressive therapy and shorter time from transplant are potential risk factors. Conversely, biliary stents provide a possible protective effect. These findings underscore the need for a larger sample size to validate emerging risk factors and develop targeted preventive strategies.

References

1. Catron TD, Shipley L, Johnson D, et al. Differences in post-ERCP adverse event rates between post-liver trans-
plant patients and patients with native hepatobiliary anatomy. Gastrointestinal Endoscopy. 2019
2. Li GZ, Wang F, Fang J, Zha HL, Zhao Q. Risk Factors for Post-Endoscopic Retrograde
Cholangiopancreatography Pancreatitis: Evidence from 1786 Cases. Med Sci Monit. 2018
3. Ambrus RB, Svendsen LB, Hillingsø JG, Hansen ML, Achiam MP. Post-endoscopic retrograde
cholangiopancreaticography complications in liver transplanted patients, a single-center experience. Scand J
Surg. 2015

Introduction

Gastrointestinal endoscopy advancements have improved diagnostics and treatment but also increased the risk of adverse events, potentially affecting the psychological well-being of practitioners. This study aims to assess the psychological state experienced by Portuguese gastroenterologists following endoscopic adverse events in endoscopic procedures.

Aims & Methods

A nationwide online survey was conducted between November 2024 and January 2025, with invitations sent to all registered Portuguese gastroenterologists (n=709). Psychological state was assessed using validated scales assessing psychological distress (DASS-21), professional quality of life (ProQOL-5), self-compassion (SCS-12), and shame feelings (OAS2). Results are presented as median (Mdn) and interquartile range (IQR).

Results

Seventy gastroenterologists participated in the study (Mdn age 41 years; experience 11 years; both IQR 11), with a 9.87% participation rate. Nearly all (n=69) had encountered adverse events, with most reporting 1–5 incidents. None sought psychological support after the adverse events, 6 faced legal repercussions, and 3 discontinued specific techniques. DASS-21 had a Mdn of 6.00 (IQR 12.00) for stress (mild if <10), 4.00 (IQR 8.00) for anxiety (mild if <6), and 4.00 (IQR 6.00) for depression (mild if <10). ProQOL-5’s total score Mdn was 41.00 (IQR 6.50) for compassion satisfaction, 25.5 (IQR 7.00) for burnout, and 24.00 (IQR 6.25) for traumatic stress, all within the moderate range (23–41). OAS2 shame score was 16.00 (IQR 7.30). Self-compassion showed a Mdn of 3.46 (IQR 1.00; moderate if 2.3–3.5). Gastroenterologists with legal repercussions had higher compassion satisfaction (52.50 vs. 33.33; p = 0.025). Those who discontinued procedures reported higher anxiety levels (56.17 vs. 31.88; p = 0.026), but no other significant differences were found.

Conclusion

This is the first published study assessing the psychological state of adverse events on gastroenterologists. While most reported mild to moderate distress, legal repercussions were associated with higher compassion satisfaction, and stopping procedures correlated with higher anxiety. Findings suggest a need for psychological support after endoscopic adverse events, and for research on their impact on gastroenterologists.

Introduction

Spontaneous bacterial peritonitis (SBP) is a well-recognized decompensation that significantly affects the clinical outcome of patients with liver cirrhosis. The aim of this study is to assess the factors associated with short-term mortality in this patient population.

Aims & Methods

We conducted a retrospective study (January 2022 to December 2024) on all cirrhotic patients with SBP, admitted in the Gastroenterology Department of “St. Spiridon” County Clinical Emergency Hospital Iasi, a tertiary referral center. The SBP cases were identified based on elevated ascitic fluid absolute PMN count > 250 cells/mm³, with or without positive ascitic fluid bacterial culture.

Results

Out of the 114 cirrhotic patients diagnosed with SBP for the first time, 39 (34,2%) were female and 75 (65,8%) were male, with a mean age of 57 years. Most patients had advanced liver disease according to the Child-Pugh classification: 98 patients (86%) were classified as Child C, and 16 patients (14%) as Child B. The mean MELD-Na score was 23.3 points. The overall in-hospital mortality rate was 17.5% (20 patients). According to the multivariable analysis, several factors were significantly associated with in-hospital mortality, such as: renal dysfunction (OR 8.4118 [95% CI 2.9190 to 24.2403]; P=0.0001), serum bilirubin higher than 3 mg/dl (OR 4.8571 [95% CI 1.7445 to 13.5216]; P=0.0025), serum sodium lower than 130 mmol/l (OR 4.3750 [95% CI 1.5973 to 11.9833]; P=0.0041), international normalized ration (INR) higher than 2 (OR 4.5222 [95% CI 1.6471 to 12.4161]; P=0.0034).

Conclusion

Renal dysfunction, elevated INR, hyperbilirubinemia, and hyponatremia appear to be significant factors associated with the worsening of prognosis in cirrhotic patients with SBP, influencing in-hospital mortality.

Introduction

Recent studies have revealed that liquid-liquid phase separation (LLPS) plays a critical role in tumorigenesis. Myotilin (MYOT), a key component of actin cross-linking protein complexes, is involved in regulating myofibril assembly and maintaining the structural integrity of Z-discs in muscle cells. Intriguingly, MYOT contains intrinsically disordered regions (IDRs) and has been implicated in the migration of gastric cancer. However, whether MYOT undergoes LLPS and whether this process contributes to gastric cancer progression remains unexplored.

Aims & Methods

We aimed to investigate whether MYOT undergoes LLPS and its potential role in gastric cancer progression.
Differential gene expression analysis was performed on gastric cancer samples from our sequencing data and validated using public databases. The Disprot, Database of Protein Disorder was used to predict the IDRs of MYOT. Fluorescence recovery after photobleaching (FRAP) and cellular immunofluorescence were explored to assess MYOT’s ability to undergo LLPS. Cell proliferation, apoptosis and migration assay were conducted to investigate the potential role of MYOT in gastric cancer. Actin polymerization assays were performed to evaluate the qualitative effects of purified MYOT on actin polymerization.

Results

Differential gene expression analysis revealed that MYOT was significantly downregulated in gastric cancer tissues compared to adjacent normal tissues, a finding further confirmed by RT-qPCR. In the prediction of protein structure, it can be found that MYOT contains extensive IDRs. FRAP analysis demonstrated rapid fluorescence recovery in GFP-MYOT droplets within minutes, suggesting dynamic LLPS behavior. Similarly, purified GFP-MYOT exhibited fusion behaviors, further supporting its capacity for LLPS in vitro. Overexpression of MYOT did not significantly affect gastric cancer cell proliferation or apoptosis, but reduced cell migration. Actin polymerization failed to occur both in the GFP-MYOT and GFP control samples.

Conclusion

Our findings demonstrate that MYOT suppresses gastric cancer cell migration and purified GFP-MYOT does not directly promote on actin polymerization, implicating its potential role as a tumor suppressor. Additionally, MYOT undergoes LLPS both in vitro and in vivo, as evidenced by FRAP. We propose that MYOT may exert its anti-tumor effects through LLPS-mediated mechanisms, offering a novel perspective on its function in gastric cancer progression.

Introduction

Endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell carcinoma (SESCC) involving the entire circumference carries the extremely high risk of stricture and also raises concerns about curative resection. Therefore, the current Japanese guidelines weakly recommend ESD only for circumferential SESCCs diagnosed as cEP/LPM and sized ≤ 50 mm, while surgery or chemoradiotherapy (CRT) is recommended for circumferential SESCCs other than the above. ¹ However, in clinical practice, ESD is implemented on a case-by-case basis through the discussion in a multi-disciplinary cancer board at each institution because the outcomes of each treatment for circumferential SESCCs remain unclear.²

Aims & Methods

This multicenter prospective observational study aimed to reveal the outcomes of each treatment for circumferential SESCCs. Patients with cT1a-EP/LPM or cT1a-MM/T1b-SM1 N0M0 SESCCs involving the entire circumference were enrolled in this study. At this stage, short-term outcomes, such as the proportion of curative resection after ESD, complete response (CR) after CRT/radiotherapy (RT), and adverse events including esophageal stricture, were evaluated. Curative resection in ESD was defined as pT1a without lymphovascular invasion (LVI). Esophageal stricture was defined as inability to pass the ordinary-sized endoscope thorough the treated site, and refractory stricture was defined as stricture requiring ≥ 6 endoscopic balloon dilation procedures.

Results

A total of 126 patients with circumferential SESCCs were enrolled from 16 Japanese tertiary institutions between May 2021 and November 2024. ESD was performed for 90 (71.4%) patients including 6 undergoing stepwise ESD, surgery for 18 (14.3%), CRT for 16 (12.7%), and RT alone for 2 (1.6%). Median longitudinal length of tumor was 55 (range: 30–140) mm in the ESD group, 80 (50–150) mm in the surgery group, and 70 (30–100) mm in the CRT/RT group. Tumor depth was diagnosed as cEP/LPM in 65.4% (55/84) of the ESD group, 38.9% (7/18) of the surgery group, and 50.0% (9/18) of the CRT/RT group, and the others were diagnosed as cMM/SM1. As stricture prevention method after ESD, local injection or filling of triamcinolone (TA) alone was used in 9 patients (10.7%), and both local injection of TA and oral steroid of prednisolone were used in 75 (89.3%). Among the 63 patients who did not receive additional treatment after ESD, the proportion of stricture and refractory stricture were 46.0% (29/63) and 27.0% (17/63), respectively. Curative resection after ESD was achieved in 58 patients (69.0%), including 46 (83.6%) with cEP/LPM and 12 (41.4%) with cMM/SM1. Of 26 patients with non-curative resection after ESD, 20 (76.9%) received additional treatment of either surgery, CRT, or RT, while the remaining 6 opted for follow-up. Of 18 patients in the surgery group, 7 with cEP/LPM and 4 with cMM/SM1 were diagnosed as pT1aN0 without LVI, while the remaining 7 with cMM/SM1 were diagnosed as pT1b, 3 of whom had lymph node metastasis. Anastomotic stricture was observed in 11.1% (2/18) of patients treated with surgery. Of 18 patients in the CRT/RT group, CR was confirmed in all patients without forming stricture.

Conclusion

Considering the high curative resection rate, ESD could be indicated for circumferential SESCCs diagnosed as cEP/LPM. In contrast, the careful consideration may be required in indicating ESD for circumferential SESCCs diagnosed as cMM/SM1 due to its low curative resection rate. Long-term outcome needs to be confirmed for further treatment comparisons.

References

1. Ishihara R, Arima M, Iizuka T, et al. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer. Dig Endosc. 2020; 32: 452–93.
2. Kadota T, Ishihara R, Hatta W, et al. Multi-institutional questionnaire on treatment strategies for superficial entire circumferential esophageal squamous cell carcinoma. DEN Open. 2023; 3: e206.