Introduction

The pancreas plays an important role in metabolic regulation. Diseases such as diabetes and obesity may benefit from local therapeutic delivery to improve on-target efficacy, safety, and durability while limiting off-target safety risks. Advancements in adeno-associated virus (AAV)-based technologies have expanded the applicability of gene therapy as a one-time treatment strategy for metabolic diseases. Local AAV delivery has the potential to revolutionize gene therapy treatment if it can be delivered safely. We developed a novel AAV-based gene therapy platform and proprietary endoscopic ultrasound (EUS)-guided automated delivery system that directly targets the pancreas, maximises AAV activity, and minimises safety concerns.

Aims & Methods

The aim of this study was to assess the feasibility and safety of infusing AAV gene therapy into the pancreas in a Yucatan pig model. A linear echoendoscope and 25-gauge needle integrated with an automated fluid delivery system were used to optimize the infusion of AAV into the pancreatic splenic lobe (porcine equivalent to human pancreas body and tail). Toluidine blue (TBO) dye, vehicle, and AAV-driven green fluorescent protein (GFP) expression were used to evaluate procedural parameters, safety, and pancreatic distribution. Necropsies were performed at 1 hour post-TBO (n=4) and 3-4 weeks post-AAV (n=11) and vehicle infusions (n=2). Pancreatic tissue was collected for characterisation of either TBO dye, AAV genomes, or AAV-GFP expression to confirm on-target efficiency. Serum alanine transaminase (ALT) and lipase were evaluated from baseline up to 4 weeks post-procedure to establish procedural safety.

Results

In TBO-infused pigs, dye was extensively distributed throughout the targeted region with minimal distribution in untargeted regions indicating that established device and procedural parameters could effectively target the splenic lobe of the pancreas. AAV-GFP infusion demonstrated localised dose-dependent biodistribution in the pancreas with robust activity in up to 80% of cells in the targeted splenic lobe as evidenced by histological GFP expression at 3 weeks post-procedure (62±10% SEM, n=4, highest dose=1.5e14 vector genome [VG]). Untargeted duodenal and connecting pancreatic lobes showed minimal GFP expression underscoring the on-target efficiency of the device and procedure. Over the course of the study, 17 pigs were successfully infused with no sign of procedure-related adverse events or acute pancreatitis. Mean serum ALT remained in the normal range across all time points measured. Mean serum lipase remained in the normal range across most timepoints evaluated with a transient elevation (~2.5x above baseline) detected at 4 hours post-procedure in one AAV-treated animal, which resolved by 72 hours. At 3-4 weeks post-procedure, elevations in serum lipase were detected and attributed to durable expression and immunogenicity of the foreign GFP reporter as pancreatic GFP expression and lipase were significantly correlated (r=0.60, p=0.032, N=13).

Conclusion

This study provides proof of concept that a novel EUS-guided automated delivery system for gene therapy can effectively target the pancreas with an encouraging preliminary safety profile. This local gene therapy approach may provide a new platform for one-time, durable treatment of metabolic diseases including diabetes and obesity.

Disclosure

CCT: consultant/research support–Apollo Endosurgery, Olympus/Spiration, GI Dynamics, Boston Scientific, Endoquest Robotics, FujiFilm, Lumendi; consultant/advisory board–Fractyl, Xenter; consultant/advisory board/research support–USGI Medical; consultant–Medtronic; research support–Aspire Bariatrics, ERBE; founder/consultant/board member–Enterasense Ltd, EnVision Endoscopy; founder/board member/ownership interest–GI Windows; general partner–BlueFlame Healthcare Venture Fund. JW, APL, EC, JC, and HR: employees and shareholders of Fractyl Health, Inc. LSL and RPT: consultants for Fractyl Health, Inc.

Introduction

Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) can demonstrate microvascularization of the tumors. However, most images acquired from CEH-EUS are interpreted subjectively without quantification by time-intensity curves (TICs) analysis.

Aims & Methods

In this study, we used handcrafted software to quantify CEH-EUS images for objective interpretation of tumor microvascularization to make differential diagnosis of pancreatic tumors feasible.
We analyzed the videos of CEH-EUS for pancreatic tumors from the patients in National Taiwan University Hospital and Far Eastern Memorial Hospital. The convex-type echoendoscope (GF-UCT260; Olympus, Tokyo, Japan) equipped with ultrasound (US) systems (EU-ME2) was used for the procedures. The second generation of US contrast agent with Sonazoid (GE Healthcare, Milwaukee,Wisc), which contains perfluorobutane microbubbles with a median diameter of 2–3 μm, was administered bolus and intravenously with a dosage of 0.015 ml encapsulated gas per kilogram body weight. The videos were recorded in AVI formats with 30 frames/second.
The algorithm for getting TICs includes the following steps:
(1) Circling the region of interest(ROI) in the B-mode
(2) Performing speckle tracking of the ROI in the B-mode
(3) Simultaneously obtaining the intensity of ROI (the mean pixel values in the ROI) in the corresponding contrast-enhanced harmonic image
(4) Outputting TICs after subtracting the baseline intensity (defined as mean TIC in the first 10 s for eliminating the different baseline intensities caused by other settings).
(5) Outputting histogram of pixel values and excel file containing all pixel values from the frame with the highest mean pixel value automatically.
(6) Calculating the standard variance of (5) to represent the heterogeneity inside the ROI.
The speckling tracking composes of searching and matching processes. We used full search for the searching process and normalization cross-correlation for the matching process. By using the hardware of CPU with Intel i7-8750H and GPU with Nvidia GTX 1050 Ti, the computation time was 0.7 ms/frame.

Results

The detailed results were shown in Table 1. We collected 10 and 7 videos of CEH-EUS for pancreatic tumors from NTUH and FEMH respectively in this study. Among them, 9 were diagnosed of pancreatic ductal adenocarcinoma (PDAC), 6 were pancreatic neuroendocrine tumors (PNET), and 2 were autoimmune pancreatitis (AIP). The TICs were obtained through our proposed model. Briefly, there were no significant differences in times to peak, the mean peak intensity, the in-slope tangent and standard deviation of pixel value in ROI (from the frame with the highest mean pixel value) among PDAC, PNET, and AIP. However, there was significant difference in the mean peak intensities of PDAC and non-PDAC (37.88 vs 63.12, p=.031).

Table 1.The results from three kinds of pancreatic tumors based on the proposed model

Conclusion

In this study, there were no significant differences in times to peak, the mean peak intensity, and SD of pixel value in ROI (from the frame with the highest mean pixel value) among PDAC, PNET, and AIP, however there was significant difference in the mean peak intensity between PDAC and non-PDAC group. A study with larger test number is needed in the future for further application.

Disclosure

We have no conflicts of interest to disclose.

Introduction

Mucinous cysts of the pancreas are known precursors of pancreatic ductal adenocarcinoma. International guidelines for management and surveillance of pancreatic cysts advise surgical resection of high-risk lesions - mucinous cystic neoplasms (MCNs) and main duct intraductal papillary neoplasms (IPMNs), especially in those with worrisome clinicopathological stigmata. For low-risk cysts, lifelong radiographic surveillance is the standard approach, which can be psychologically distressing for patients and burdensome for healthcare systems. Endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA) of high-risk cystic lesions of the pancreas is increasingly being used as a minimally invasive alternative in patients who are unfit for or who decline surgery (1). We assessed the safety and efficacy of EUS-guided RFA in the management of low-risk cystic lesions of the pancreas.

Aims & Methods

68 patients (29M, 39F; mean age 63, range 33-82 years) with low-risk mucinous cystic neoplasms of the pancreas (branch-duct IPMN/mucinous cystadenomas, 0.7-4cm in size) were recruited for treatment by EUS-RFA. The primary endpoint was change in size of the pancreatic cyst on cross-sectional imaging (MRI) at one year after treatment (efficacy). Secondary endpoints included progression following treatment, procedure related morbidity and local complication rate (safety).

Results

68 patients were recruited of whom 55 completed RFA ablation of their cyst. Anatomical concerns (i.e., blood vessel, main duct proximity) precluded RFA in 12 patients. 18/55 patients (33%) underwent a second ablation. Follow up imaging data were available for 46 (84%) patients and showed a <20% reduction in cyst size in 18 patients, 20-49% in 4 patients, 50-79% in 5 and 80-100% size reduction in 18 patients. For one patient, doubling in cyst size was recorded at the 12-month follow-up. Excluding one case of scope-induced small bowel perforation (Clavien-Dindo; ClvD grade 3), other adverse events were mild (ClvD 0-2) and expected (transient abdominal pain, bloating, sore throat, nausea/vomiting). One patient experienced a self-limiting, post procedure grand mal seizure on a background of epilepsy.

Conclusion

​EUS-RFA was well tolerated in most cases. Our data indicate that the procedure is relatively safe. The response ranged from a <20% reduction in size to complete cyst resolution.

References

1. Papaefthymiou A, Johnson GJ, Maida M, Gkolfakis P, Ramai D, Facciorusso A, Arvanitakis M, Ney A, Fusai GK, Saftoiu A, Tabacelia D, Phillpotts S, Chapman MH, Webster GJ, Pereira SP. Performance and safety of EUS-ablation techniques for pancreatic cystic lesions: a systematic review and meta-analysis. Cancers 2023 [in press].

Disclosure

No conflict of interest

Introduction

Current endoscopic ultrasound technologies (EUS) are suboptimal in the assessment of pancreatic cystic lesions (PCLs). We developed a new through-the-needle brush, the "loop brush", to improve the cellular yield, and thereby sensitivity, of EUS fine needle aspiration (EUS-FNA) of pancreatic cysts.

Aims & Methods

We aim to evaluate the "loop brush" safety, robustness, and efficacy.
We performed an in-vivo randomized controlled trial in pigs using artificial cysts. In one group, the loop brush was deployed through a 22G EUS-FNA needle into the cysts. In the control group, cystic punction was performed with standard EUS-FNA. Loop brushes were visually inspected post-procedure. Cytological assessment, cell counting, and hemoglobin analysis were performed in samples from both groups.

Results

Artificial cysts (n=114) were punctured in six pigs, 57 in each group. Neither adverse events nor significant device malfunction occurred during loop brushing. Samples collected with the brush had non-detectable concentrations of hemoglobin in 72% (41/57) of cases, and 26% (16/57) had less than 0.6 g/dL, with no significant difference to the controls (p=0.32). Brushing cell counts were associated with significantly increased cell counts (11.7× median difference, p<.0001). Cytological smears
were diagnostic in 77% of cases in the brushing group, while 54% in the control group (p=0.01, Fisher’s exact test; p=0.006, Chi-square test).

Conclusion

The new loop brush procedure appears to be safe, causing neither significant bleeding nor device malfunction. Samples obtained with the loop brush were suitable for cytological analysis and showed significantly higher cell yield than controls. Further clinical studies are warranted.

References

DOI: 10.1053/j.gastro.2020.10.007
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DOI: 10.3389/fonc.2021.688377
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DOI: 10.1038/ajg.2018.14
Mohamed, E.; et al. Role of radiological imaging in the diagnosis andcharacterization of pancreatic cystic lesions: a systematic review. Pancreas 2018, 47, 1055–1064.
Cazacu, I. M.; et al. A quarter cen- tury of EUS-FNA: Progress,milestones, and future directions. Endoscopic ultrasound 2018, 7, 141
DOI: 10.1038/s41598-021-81065-2
doi: 10.4103/eus.eus_93_17
Shirley, L. A.; et al. Routine cyst fluid cytology is not indicated in the evaluation of pancreatic cystic lesions. Journal of Gastrointestinal Surgery 2016, 20, 1581–1585.
Muniraj, T.; et al. Devices for endoscopic ultrasound-guided tissue acquisition. Techniques in Gastrointestinal Endoscopy 2018, 20, 2–9.
Balaban, V. D.; et al. EUS- through-the-needlemicrobiopsy forceps in pancreatic cystic lesions: A systematic review. Endoscopic Ultrasound 2021, 10, 19.
Marques, F.; et al. A loop-shaped minimally invasive brush for improved cytology sampling of pancreatic cysts during EUS-FNA. Medical Devices & Sensors 2021, 4, e10165.
doi: 10.1177/0271678X20943823.
doi: 10.3748/wjg.v18.i34.4659
DOI: 10.3748/wjg.v27.i26.4194

Disclosure

FM, WW, UA, NR, and FBS have patent applications for the brush technology and are co- founders of Lucky LoopMedical AB, a company commercializing technology for improved sampling in EUS-FNA. UA has received a research grant from Boston Scientific and is a consultant to Boston Scientific, Medtronic, and Ambu. IS declares no conflict ofinterest.

Introduction

Hemorrhoidal disease (HD) is the most common pathology in proctology, with an estimated prevalence of between 4.4% and 39%. It can be managed in a variety of ways: hygienic-dietary measures, medical, instrumental or surgical treatment. The latter is considered especially after failure of medical and instrumental treatment.

Aims & Methods

Aims : The aim of our study is to report our experience with Milligan and Morgan technique in the management of hemorrhoidal disease.

Materials and methods: This was a monocentric retrospective descriptive-analytical study conducted over a 12-year period: from January 2011 to January 2023. The data studied were age, sex, clinical manifestations, stage of HD on proctological examination and therapeutic data. All patients who underwent Milligan and Morgan hemorrhoidectomy (MMH) and presented with stage IV and III hemorrhoids (after failure of instrumental treatment) were included in our study. Excluded were asymptomatic patients, patients with surgical contraindications and other stages treated by non-surgical means. The statistical study was carried out using IBM-SPSS 20.0 software. The chi-2 test was used to compare categorical variables.

Results

468 patients were enrolled during the study period. The mean age of this population was 41 years (22-71). The sex ratio M/F was 2,1. Clinical expression was dominated by rectal discharge in 246 patients (74%), proctalgia in 132 patients (28%), anal pruritus in 119 patients (25%) and anal oozing in 56 patients (12%). Proctological examination revealed stage IV haemorrhoids in 201 patients (43%) and stage III haemorrhoids in 267 patients (57%). 25 patients (5.3%) had an associated anal fissure. Anemia was present in 341 patients (72.8%), with a mean hemoglobin value of 7.8 g/dl. Transfusion was required in 65 patients (14%) who presented with severe anemia of less than 7g/dl. Colonoscopy was indicated in 87 patients (18.5%) over the age of 45 with rectal bleeding, and in 42 patients (9%) with a history of digestive cancer. Milligan and Morgan's indication was stage III hemorrhoids with severe anemia in 65 patients (14%), after failure of infrared photocoagulation in 194 patients (41.4%); after failure of HAL-RAR treatment n=8 (1.7%) and stage IV hemorrhoids in 201 patients (43%). The procedure performed was a hemorrhoidectomy.An open pedicle MMH type was performed. Patients with an associated anal fissure (5.3%) underwent the Bellan procedure in addition to hemorrhoidectomy. Immediate post-operative complications included post-operative pain in all our patients, urinary retention in 31 patients (6.6%), significant post-operative bleeding in 2 patients (0.5%) treated by electrocoagulation in the OR, and minimal post-operative bleeding in 117 patients (25%) treated by compression bandaging. The latter was reported in 43 patients (36.7%) with stage III hemorrhoids and 74 patients (63.2%) with stage IV hemorrhoids. This difference was statistically significant (p<0.001). Late complications included delayed healing in 9 patients (1.9%), 4 of whom were diabetic, anal stenosis in 5 patients (1%), requiring sphincterotomy combined with anoplasty in 3 patients, and finger dilatation in 2 patients. Anal stenosis was reported in 4 patients who did not undergo postoperative digital rectal examination and 1 patient who did. This difference is statistically significant p=0.03.

Conclusion

MMH remains the gold standard for the treatment of hemorrhoidal disease. The results are satisfactory, especially in the long term. Post-hemorrhoidectomy anal stenosis remains the most serious complication.

Clinical Case Summary

A 40-year-old male came to our emergency department referring worsening jaundice, mental status deterioration, epigastric pain and anorexia over the past week. Four weeks earlier he presented odynophagia, myalgias, and hand pruritus but didn’t seek medical attention.
Patient’s clinical background included cognitive impairment due to peripartum anoxia and type 2 Diabetes Mellitus. At admission, he had elevated liver enzymes (R value=2,7), coagulopathy (INR 1.3), pancreatic enzymes >3 times the upper normal level and hyperbilirubinemia (mostly conjugated).
The CT-scan revealed pancreatic tail globosity, diffuse abdominal and retroperitoneal peri-centimetric lymph nodes and excluded biliary lithiasis.
After common causes of acute hepatitis and pancreatitis were ruled out, and since patient was at risk of acute liver failure despite supportive treatment, a liver biopsy was performed. Autoimmune hepatitis, drug-induced liver injury or lymphoproliferative disease were held as potential differentials. Hepatitis E Virus (HEV) RNA was then found and genotyped in the serum (genotype 3). HEV infection was assumed as the cause for both hepatitis and pancreatitis. Histological pattern was inconclusive and epidemiological source wasn’t found.

HEV infection paradigm has changed and is now considered an endemic zoonotic infection in most high-income countries (Portuguese seroprevalence is 16.3%)¹. Infection occurs due to ingestion of undercooked pig or boar meat and should be suspected in every acute hepatitis, mostly with a cholestatic pattern.
The setting of acute HEV hepatitis complicated with acute pancreatitis (AP) is uncommon². AP usually starts after a median of 10 days of jaundice onset³. Literature only reports association between AP and HEV caused by genotype 1 from Southeast Asia^{3 4}, and genotype 3 was only related to gallstone-related pancreatitis, according to current knowledge⁵. This might be the first form of HEV genotype 3 infection with hepatitis and pancreatitis.

References

1. Nascimento MSJ, Pereira SS, Teixeira J, et al. A nationwide serosurvey of hepatitis E virus antibodies in the general population of Portugal. Eur J Public Health 2018;28(4):720-24. doi: 10.1093/eurpub/ckx213 [published Online First: 2017/12/14]
2. Debnath P, Datta AK, Chakraborty U, et al. Acute viral hepatitis E complicated with acute pancreatitis in an immunocompetent adult. BMJ Case Rep 2021;14(2) doi: 10.1136/bcr-2020-239684 [published Online First: 2021/02/06]
3. Haffar S, Bazerbachi F, Garg S, et al. Frequency and prognosis of acute pancreatitis associated with acute hepatitis E: A systematic review. Pancreatology 2015;15(4):321-6. doi: 10.1016/j.pan.2015.05.460 [published Online First: 2015/06/08]
4. European Association for the Study of the Liver. Electronic address eee, European Association for the Study of the L. EASL Clinical Practice Guidelines on hepatitis E virus infection. J Hepatol 2018;68(6):1256-71. doi: 10.1016/j.jhep.2018.03.005 [published Online First: 2018/04/04]
5. Karlsson M, Norder H, Bergstrom M, et al. Hepatitis E virus genotype 3 is associated with gallstone-related disease. Scand J Gastroenterol 2019;54(10):1269-73. doi: 10.1080/00365521.2019.1666163 [published Online First: 20190925]

Introduction

Preliminary data (PanCo) has suggested combined chemotherapy and endoscopic ultrasound (EUS) guided intra-tumoral phosphorus-32 (³²P) microparticles (OncoSil^TM Medical) may be beneficial in locally advanced pancreatic cancer (LAPC)¹. We report on the clinical outcomes in our Australia and New Zealand (ANZ) cohort with this combined therapy in LAPC.

Aims & Methods

This is a two-centre retrospective study from August 2017 – January 2023. All patients with non-metastatic unresectable or borderline resectable LAPC who underwent combination chemotherapy with EUS-guided intra-tumoral ³²P implantation were included from two centers in ANZ. First-line chemotherapy includes 5-fluorouracil/leucovorin, irinotecan and oxaliplatin (FOLFIRINOX) and gemcitabine and nab-paclitaxel (GNP). Outcomes including 12-week response (RECIST 1.1), resection rate and overall survival were recorded and compared between FOLFIRINOX and GNP cohorts.

Results

A total of 49 patients (male:32; median age:72 years) underwent combined therapy (FOLFIRINOX:19, GNP:30). A median ³²P microparticle volume of 1mL (IQR 0.8-1.6) was injected into pancreatic tumors (median longest diameter:29.5mm (IQR 26.7-37)). Technical success of ³²P implantation was 100% with no acute complications. Local disease control in patients 12 weeks post-implant was 96%. Fifteen patients (31%; 26.3% of patients with FOLFIRINOX vs. 33.3% of patients with GNP, p=0.074) had tumor downstaging and were theoretically resectable whilst 9 (18.4%) had successful resections (6/9 R0). Two patients are awaiting resection, one patient opted not for surgery and three patients were deemed not fit for surgery. Over a median follow-up period of 20 months (range 3-67), 55% (27/49) have had disease progression (36% local progression, 42% distant progression). Median overall survival from diagnosis was 16 months (IQR 11-21; FOLFIRINOX=14.6 months vs. GNP=16.6 months, p=0.259).

Conclusion

This is the largest reported ANZ cohort with EUS-guided ³²P implantation for patients with LAPC. Additionally, this is the largest reported cohort of patients with combined therapy with FOLFIRINOX. The results of this current study are encouraging, forming a platform for larger trials and further ANZ involvement in investigating the benefits of combined therapy in patients with LAPC. Studies comparing standard therapy and combined chemotherapy with ³²P implantation are warranted.

References

1. Ross, P.J., et al., PanCO: An open-label, single-arm pilot study of phosphorus-32 (P-32; Oncosil) microparticles in patients with unresectable locally advanced pancreatic adenocarcinoma (LAPC) in combination with FOLFIRINOX or gemcitabine + nab-paclitaxel (GNP) chemotherapies. Journal of Clinical Oncology, 2019. 37(15_suppl): p. 4125-4125