Introduction

Simple renal cyst is one of the most common diseases in the urinary system. Intervention is only considered under circumstances of large cysts (＞5cm), bleeding, recurrent infection or pain^[1]. Ethanol percutaneous sclerotherapy and laparoscopy are two main treatment modalities for simple renal cysts^[2]. However, in cases of cysts in superior renal pole, percutaneous sclerotherapy is often excluded due to the unsafety of percutaneous puncture. In recent years, endoscopic ultrasound (EUS) guided fine-needle aspiration has been proven as a safe and efficient treatment for biopsy of renal and renicapsule lesions^[3], inspired by which, we successfully performed an EUS-guided sclerotherapy on cyst in the superior renal pole^[4]. Since then, we performed nine more cases of EUS-guided sclerotherapy on cyst in the superior renal pole. This research is an retrospective analysis of the nine cases and is aimed to compare the efficacy, safety and cost-benefit analysis of endoscopic ultrasound guided sclerotherapy and laparoscopic surgery treating cyst in the superior renal pole.

Aims & Methods

To compare the efficacy, safety and cost-benefit analysis of endoscopic ultrasound guided sclerotherapy and laparoscopic surgery treating cyst in the superior renal pole.
Methods: A retrospective analysis was performed in 25 patients with cyst in the superior renal pole hospitalized in the Second Affiliated Hospital of Soochow University from January 2021 to August 2022.The efficacy, operation time, intraoperative blood loss volume, hospital stay, complications and treatment cost of EUS-guided sclerotherapy (9 cases) and laparoscopic surgery (16 cases) were compared.

Results

The EUS and laparoscopic groups had comparable efficacy (100% vs 87.5%, P=0.520). The EUS group exhibited shorter operation time (29.8±4.8 vs 70.1±11.1 min, P=0.000), less intraoperative blood loss (0 vs 26.1±5.9 ml, P=0.000), shorter length of postoperative hospital stay (3.5±0.7 vs 5.4±2.0 days, P=0.014) and lower total cost (10547.85±2388.19 vs15316.09±5352.45 yuan, P=0.019). There were no difference on total length of hospital stay(8.1±2.0 vs 9.3±3.1 days) and operation cost (3946.79±490.82 vs 3860.18.17±857.42 yuan) (both P＞0.05).

Conclusion

Compared with laparoscopic surgery, EUS-guided sclerotherapy was an effective but safer technique in treating cyst in the superior renal pole.

References

1. Richard PO, Violette PD, Jewett MA, et al. CUA guideline on the management of cystic renal lesions[J].Can Urol Assoc J. 2017, 11(3-4):E66-E73.DOI: 10.4253/wjge.v7.i3.253.
2. Eissa A, El Sherbiny A, Martorana E, et al. Non-conservative management of simple renal cysts inadults: a comprehensive review of literature[J]. Minerva Urol Nefrol. 2018, 70(2):179-192. DOI: 10.23736/S0393-2249.17.02985-X.
3. Lopes RI, Moura RN, Artifon E. Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of kidney lesions: A review[J]. World J Gastrointest Endosc. 2015, 7(3):253-7. DOI: 10.4253/wjge.v7.i3.253.
4. Wu W, Zhang Y, Hu D, Song K. EUS-guided sclerotherapy as a new therapy for renal cyst (with video)[J]. Gastrointest Endosc. 2022, 95(3):587-588. DOI:10.1016/j.gie.2021.10.029.

Introduction

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is an important diagnostic tool for suspected parenchymal lesions within the gastrointestinal tract and adjacent organs. However, the amount of literature on EUS-FNA for sampling focal liver lesions (FLLs) is limited.

Aims & Methods

This study aims at evaluating the safety and effectiveness of EUS-FNA in FLLs. Data from 88 patients who were diagnosed with FLLs by imaging and underwent EUS-FNA was reviewed in this retrospective study at the Second Affiliated Hospital of Soochow University and Ruijin Hospital of School of Medicine of Shanghai Jiao Tong University from 1 January 2017 to 31 August 2022.The EUS-FNA biopsy results were compared with the final diagnosis to evaluate the diagnostic value. Meanwhile, the relevant factors were analyzed to determine their influences on the EUS-FNA biopsy results.

Results

A final diagnosis was obtained (86 malignant and 2 benign) from the 88 cases. The overall diagnostic accuracy of EUS-FNA in FLLs was 93.18% (82／88; 95% confidence interval [CI ],87.9–98.5), with a sensitivity, specificity, positive predictive value, and negative predictive value of 93.02% (80／86; 95%CI, 87.6–98.4), 100% (2／2; 95%CI, 100–100), 100% (80／80; 95%CI, 100–100), and 25% (2／8; 95%CI, -5–55.0), respectively . The parameters related to lesion and procedure were not statistically significant between these two groups (p> 0.05) (Table 1). The number of puncture needles in the groups showed a statistically significant difference between multiple and single punctures (p = 0.001).

Conclusion

It is revealed in this study that EUS-FNA is a safe and excellent diagnostic method for FLLs with high accuracy.

Clinical Case Summary

A 50 year old paraplegic gentleman (secondary to a road traffic accident) with a diversion colostomy and preserved small bowel length, and a history of idiopathic cirrhosis, was admitted with a one week history of high output stoma. Initially felt to be infectious, he was resuscitated with volume and electrolyte replacement. Despite a negative infection, autoimmune and extended inflammatory screen, the high stoma output persisted between 4-6L per 24 hours. He subsequently developed circulatory failure due to volume losses and required intensive care support for fluid management, parenteral nutrition (PN) and inotropes. Serial cross sectional imaging showed oedematous jejunal and ileal bowel without evidence of vascular insufficiency.

His stoma output failed to respond to maximum doses of loperamide, octreotide, proton pump inhibitors or opiates. He was commenced on a trial of high dose steroids without any benefit. A colonoscopy showed grossly oedematous bowel, with biopsies demonstrating preserved crypt architecture on a background of significant oedema. He was PN dependant with challenging management of his fluid balance. Due to a new acute renal injury with nephrotic range proteinuria, further stains on his colonic biopsies were requested. These stained positive with congo red, showing apple green birefringence which was suggestive of a diagnosis of Amyloidosis.
Following consultation with the National Amyloidosis Referral Centre, further investigations were requested which showed an amyloid load in the spleen (SAP scan) and chronic pelvic sepsis (PET CT) likely to be driving a chronic inflammatory state. Due to the advance nature of his disease, no active treatment could be offered and the patient unfortunately passed away 8 months into their hospital admission due to multi-organ failure.
Through reporting of this case, we want to raise awareness of Amyloidosis as a rare cause of Type 2 intestinal failure.

Introduction

Multiple treatment choices are available for patients with either Ulcerative Colitis (UC) or Crohn’s Disease (CD) requiring a first biologic therapy, but there is very limited data on comparative efficacy of different agents. Outcomes from robust, large-scale cohort studies can help to inform therapeutic decisions.

Aims & Methods

To compare the efficacy of first line biologic therapies [infliximab (IFX), adalimumab (ADA), golimumab (GLM), vedolizumab (VDZ)] in biologic-naïve patients with UC and CD and enrolled in the UK Inflammatory Bowel Disease (IBD) BioResource. Patients receiving first-line tofacitinib and ustekinumab were excluded from the analysis due to low numbers. Demographic, disease, treatment and outcome data were retrieved. Inverse probability of treatment weighting (IPTW) was used to balance groups using a propensity score-weighting approach accounting for baseline patient or disease related clinical characteristics. Balancing success was assessed with standardized mean differences (SMDs). Effectiveness of treatment was based on persistence free of treatment discontinuation or treatment failure. Failure was defined as occurring if any of the following occurred: (a) clinician-recorded treatment failure (b)start of treatment with a different biologic drug (c)occurrence of resectional or defunctioning bowel surgery. We compared Kaplan Meier curves for treatment failure-free survival after IPTW and used a log rank test for differences between the groups.Cox proportionate hazard ratios (HR)were used for comparisons between treatments.

Results

In total, 12747 patients were included in the analysis (UC=3967, CD=8780). Over a four-year follow up period, treatment survival free of treatment failure or treatment escalation was significantly different between different treatment groups both in UC and CD (log rank p=0.007 and p=0.011 respectively). For UC, we found that VDZ was superior to all anti-TNF agents [vs GLM HR 3.4 (95% CIs 2.2-5.2), vs ADA HR 3.1 (95% CIs 2.1-4.5), vs IFX HR 1.9 (95% CIs 1.3-2.8), all p values <0.001]. When compared between anti-TNF agents IFX was superior to both ADA and GLM [vs ADA HR 1.6 (95% CIs 1.4-1.8), vs GLM HR 1.7 (95% CIs 1.3-2.2)] while no significant difference was detected when ADA and GLM were compared. For CD, IPTW did not achieve optimal balancing for baseline differences in the presence of perianal disease. Restricting analysis to the subgroup with the absence of perianal disease, we did not observe a significant difference in treatment outcomes.

Conclusion

Our study showed superiority of VDZ over anti-TNF agents in biologic naïve patients with UC. This is in accordance with, and extends the findings of, a prior head-to-head trial in UC comparing VDZ and ADA¹. In patients with luminal CD, no difference was detected between VDZ and anti-TNF agents. Our data offer guidance to physicians and patients as to relative drug efficacy for first line therapies in IBD.

References

1. Sands BE, Peyrin-Biroulet L, Loftus EV Jr, et al. Vedolizumab versus Adalimumab for Moderate-to-Severe Ulcerative Colitis. N Engl J Med. 2019;381(13):1215-1226. doi:10.1056/NEJMoa1905725

Introduction

Bacterial translocation exacerbates circulatory dysfunction present in patients with liver cirrhosis. Probiotics can reduce bacterial translocation and consequently improve the outcomes in this population.

Aims & Methods

This study aims to evaluate the efficacy of probiotics in the cirrhotic patients. We performed a systematic review in PubMed, Embase and Cochrane Central database, searching for studies analyzing the effects of probiotics use in overt hepatic encephalopathy incidence in cirrhotic patients. A Bayesian network meta-analysis was conducted to estimate the relative effects between treatments using risk ratios (RR) and to rank each one according to the Surface Under the Cumulative Ranking Curve (SUCRA).

Results

We included eight studies, comprising 975 patients. The assessment of SUCRA values indicated that lactulose plus probiotics (0.95) emerged as the most effective prevention for overt hepatic encephalopathy. Moreover, lactulose plus probiotics demonstrated superior efficacy compared to lactulose (0.54), probiotics only (0.51), LOLA (0.48), placebo (0.24), and no therapy (0.21). The risk of overt hepatic encephalopathy was low for lactulose plus probiotics (0.000025; credible interval [CrI] 1.3x1016, 1.5), lactulose only (RR 0.64; CrI 0.09, 4.0), probiotics (RR 0.69; CrI 0.17, 2.9), LOLA (RR 0.64; CrI 0.04, 8.9) and no therapy (RR 1.1; CrI 0.22, 7.0).

Conclusion

In our network meta-analysis, the best results in the treatment of the patients with cirrhosis and hepatic encephalopathy was seen with the association of lactulose plus probiotics. Both drugs have good tolerability and are widely disponible, so we suggest considering this association.

Introduction

Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/B) has been widely used for the diagnosis of solid pancreatic lesion. Studies have shown that the wet suction technique in EUS-FNA generates better histologic diagnostic accuracy and specimen quality than the dry suction technique. However, conclusions of wet suction on the diagnostic accuracy of EUS-FNB are still controversial. Besides, the optimal number of passes for EUS-FNB has not been determined. We aimed to design a multicenter randomized trial to compare the diagnostic accuracy of dry suction versus wet suction technique in solid pancreatic lesions using 22G Franseen needles and determine the optimal number of passes required for EUS-FNB without onsite cytopathologist.

Aims & Methods

This is a multi-center, open-label, randomized controlled and non-inferiority trial with two parallel groups. The patients with solid pancreatic lesion will undergo EUS-FNB using 22G Franseen needle in 4 tertiary hospitals in China and will be randomly assigned to the dry suction group and wet suction group in a ratio of 1:1. The primary endpoint of this study is to compare the diagnostic accuracy of EUS-FNB for solid pancreatic lesions using the dry or wet suction technique. Secondary endpoints include the optimal number of needle passes, sensitivity, specificity, specimen quality, time of the procedure, and rates of complications.

Results

Of the 195 patients undergoing EUS-FNB enrolled in the final analysis, 96 were randomized to the dry suction group and 99 to the wet suction group. The diagnostic accuracy was 98.95% and 98.98% in the dry and wet groups, respectively, with a 0.05% difference in accuracy between the study groups (two-sided 90% CI, -4.88% to 4.82%, P=0.989). Diagnostic accuracy was shown to be non-inferior because the lower bound of the 90% confidence interval falls to the right of the non-inferiority margin. Compared to the wet group, no significant differences were seen in the sensitivity (98.80 % vs 98.77 %, P = 1) and specificity (100 % vs 100 %, P = 1) in the dry suction group. The overall adverse event rate was 0.52 %, with 0 and 1.02 % in the dry and wet groups, respectively (P = 1). In terms of specimen quality, no significant differences were also seen in the two groups in sample adequacy (100 % vs 98.3 %, P = 0.492) and level of blood contamination (P = 0.319). In terms of puncture time in the dry group compared to the wet group, there was no statistically significant (18.82±8.21 min vs. 18.92±8.99 min, P=0.952), but the wet suction required more time to prepare the saline and the needle. No significant improvement in diagnostic accuracy was seen with the 2nd needle compared to the 1st needle of EUS-FNB (97.41% vs 95.34%，P=0.276), and no significant improvement in diagnostic accuracy was seen with the 3rd shot compared to the 2nd shot of EUS-FNB (98.96% vs 97.41%，P=0.446).

Conclusion

The dry suction technique is non-inferior to the wet suction technique, while saving steps and time. In the absence of rapid on-site evaluation (ROSE), only 1 pass was required to reach the diagnositic accuracy≥ 95% using EUS-FNB with Franseen needle.

Disclosure

The authors disclose no conflicts.