Introduction

The clinical course after surgery in Crohn’s Disease (CD) patients ileo-colonic anastomosis (ICA) is well known. Differently, clinical outcome in patients with entero-enteric anastomosis (EEA) after isolated small bowel resection is undefined.

Aims & Methods

The primary aim of the present case-control study was to search for differences in terms of major clinical outcomes at 5 years between CD patients with EEA (Cases), when compared to CD patients with ICA (Controls) matched for age and smoking status before index surgery. Secondary aim was to compare the characteristics of CD and the disease course before index surgery in Cases versus Controls.
All CD patients with EEA were retrospectively enrolled and matched for age at diagnosis (+/- 5 years) and smoking status before index surgery with 2 CD Controls with ICA. Inclusion criteria: 1) age ≥18; 2) EEA or ICA for CD; 3) ≥5-years follow-up after index surgery. Exclusion criteria: 1) missing data; 2) ostomy; 3) stricturoplasty. Data were expressed as median [range]. The Student-t-test, X2 test, Kaplan-Meier curves and logistic regression analyses were used as appropriate.

Results

Cases included 51 CD patients with EEA (ileum-ileum 39 [76.5%], jejunum-ileum 6 [11.8%], jejunum-jejunum 5 [9.8%], duodenum-jejunum 1 [1.9%]). Matched Controls included 102 CD patients with ICA. At 3 and 5 years after surgery, clinical recurrence was more frequent in Cases (28 [54.9%] vs. 37 [36.3%], p=0.04; 34 [66.7%] vs. 43 [42.2%], p=0.007). Cases showed a higher frequency of CD-related hospitalization ≤5 years after surgery (25 [49%] vs. 23 [22.5%], p=0.001]) (Table). In Cases, corticosteroids use was more frequent at 1, 3 and 5 years (14 [27.5%] vs. 8 [7.8%], p=0.002; 21 [41.2%] vs. 15 [14.7%], p=0.0006; 26 [50.9%] vs. 18 [17.6%], p<0.0001) (Table). ISS and biologics use 3 and 5 years after surgery was more frequent in Cases (20 [39.2%] vs. 20 [19.6%], p=0.01; 21 [41.2%] vs. 24 [23.5%], p=0.03; (15 [29.4%] vs. 13 [12.7%], p=0.02 and 23 [45.1%] vs. 15 [14.7%], p=0.03) (Table). Cases showed a shorter time to survival from clinical recurrence and hospitalization (2.36 [1.29-4.35], p=0.0036; 1.71 [1.06-2.77], p=0.02). EEA and ISS use before index surgery were risk factors for CD-related hospitalization and clinical recurrence at 5 years (2.68 [1.11-6.45]; p=0.02, 2.61 [1.21-5.6]; p=0.01 and 2.53 [1.05-6.09]; p=0.03; 2.44 [1.18-5]; p=0.01).

Conclusion

The clinical outcome after surgery is more severe in CD patients with EEA versus ICA, being associated with a higher rate of clinical recurrence, hospitalization and need of major treatments for the disease. This suggests the need of a tight assessment after isolated small bowel surgery, in order to achieve a timely and appropriate treatment and possible prevention of complications.

References

1) Onali S, Petruzziello C, Calabrese E, Condino G, Zorzi F, Sica GS, Pallone F, Biancone L. Frequency, pattern, and risk factors of postoperative recurrence of Crohn's disease after resection different from ileo-colonic. J Gastrointest Surg. 2009; 13 (2): 246-252.
2) Bemelman WA, Warusavitarne J, Sampietro GM, Serclova Z, Zmora O, Luglio G, de Buck van Overstraeten A, Burke JP, Buskens CJ, Francesco C, et al. ECCO-ESCP Consensus on Surgery for Crohn’s Disease. J. Crohns Colitis. 2017; 12: 1-16.

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.

Introduction

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an effective treatment for patients in whom transpapillary biliary drainage fails. However, EUS-HGS is associated with a high incidence of early procedure-relatedadverse events (PRAEs) due to bile leakage through a biliogastrointestinal fistula.

Aims & Methods

This multicenter study retrospectively evaluated the clinical outcomes of EUS-HGS. This study included 222 patients (120 men, 102 women; median age, 73 years) who underwent initial EUS-HGS between November 2014 and August 2024. Technical and clinical success rates, PRAEs, and stent dysfunction rates were analyzed. PRAEs were defined as adverse events occurring within 2 weeks according to the assessment of the American Society for Gastrointestinal Endoscopy.

Results

Benign and malignant tumors were observed in 18 (8.1%) and 204 (91.9%) patients, respectively. The median procedure time for EUS-HGS was 41 min (range, 11–173 minutes). Plastic and metal stents were deployed in 51.4% and 48.6% of the patients, respectively. Technical and clinical success rates and PRAEs were 97.8%, 85.1%, and 22.1%, respectively. The PRAEs were classified into mild (16.7%), moderate (4.1%), or severe (1.4%). Recurrent biliary obstruction (RBO) occurred in 51 (23.1%) patients. The median time to RBO in the metal stent group was significantly longer than that in the plastic stent group (313 vs. 162 days, P=0.02). Multivariate analysis identified the use of any dilation device (P=0.01; odds ratio [OR]: 3.55; 95% confidence interval [CI]: 1.35–9.36) and concomitant antegrade stenting (P=0.03; OR: 2.62; 95% CI: 1.12–6.12) as risk factors for PRAEs.

Conclusion

EUS-HGS is feasible; however, careful follow-up is required for patients undergoing fistula dilation and concomitant antegrade stenting.

Introduction

Current colonoscopy quality indicators recommend a minimum withdrawal time (WT) of 6 minutes. However, this standard may reduce colonoscopy efficiency and does not account for endoscopists' experience or bowel preparation quality. This study aims to investigate whether the 6-minute WT remains necessary for experienced endoscopists with excellent bowel preparation (BBPS≥8) by comparing the impact of 5-minute versus 6-minute WT on adenoma detection rate (ADR) and adenoma miss rate (AMR).

Aims & Methods

This study based experienced endoscopists and excellent bowel preparation (Boston Bowel Preparation Scale score, BBPS≥8) is aimed to compare the effect of 5-minute WT versus 6-minute WT on adenoma detection rate (ADR) and adenoma miss rate (AMR).
This multicenter, randomized controlled trial involving 423 patients was conducted from June 2023 to March 2025 in 5 centers, including Wuxi People's Hospital, Jiangsu Province People's hospital, Xuzhou First People's Hospital, The Second Affiliated Hospital of Soochow University, Taizhou People's Hospital. Colonoscope was inserted and withdrew twice on each patient and all procedures for the same patient were done by the same endoscopist. Participants were randomly divided into the 5-minute WT group (the first WT-5-minute and the second WT-6-minute, n =214) and the 6-minute WT group (the first WT-6-minute and the second WT-6-minute, n=209), and a timer was used to adjust the withdrawal speed. The primary outcome was ADR and AMR.

Results

The baseline characteristics of the two groups were similar (Table 1) and colonoscopy characteristics of the patients in the two groups regarding quality of bowel preparation, cecal intubation rate, cecal intubation time, cecal intubation distance, number of abdominal compression, number of position change were comparable (Table 2). Overall ADR (39.7% vs 43.5%, P = 0.425), ADR in the first (36.0% vs 36.4%, P = 0.935) and second withdrawal (10.7% vs 13.9%; P = 0.327) were not significantly increased in the 6-minute WT group compared with the 5-minute WT group. Likewise, the overall advanced adenoma detection (AADR) (4.7% vs 5.3%, P = 0.780), AADR in the first (4.7% vs 5.3%, P = 0.780) and second withdrawal (0.5% vs 0.5%, P = 0.745) did not differ statistically. Further analysis showed that AMR (10.7% vs 13.9%, P = 0.372) was lower in the 5-minute WT group than in the 6-minute WT group, less adenomas were missed in the 5-minute WT group, although not statistically significant (Table 3).
Table 3. Lesion-level detection and miss rate in the two groups
PDR, polyp detection rate; ADR, adenoma detection rate; AADR, advanced adenoma detection rate; AMR, adenoma miss rate; AAMR, advanced adenoma miss rate; PMR, polyp miss rate.
Table 3. Lesion-level detection and miss rate in the two groups

Conclusion

Shortening WT from 6 to 5 minutes didn't reduce ADR based experienced endoscopists and excellent BBPS, a 5-minute WT benchmark was acceptable with experienced endoscopists and excellent bowel preparation quality of colonoscopy.

Introduction

Accurate prediction of lymph node metastasis (LNM) in submucosal invasive (T1) colorectal cancer (CRC) is essential for determining the need for additional surgery following endoscopic resection. Conventional histopathological assessments, however, are limited by interobserver variability. This study aimed to develop and externally validate a stacking-based artificial intelligence (AI) model integrating histopathological whole slide images (WSIs) and clinical parameters to predict the risk of LNM in T1 CRC.

Aims & Methods

This retrospective study included 1,056 patients with histologically confirmed T1 CRC treated at Showa Medical University Northern Yokohama Hospital. Of these, 593 cases were used for model training and 100 for internal testing. External validation was conducted on 25 cases from two independent institutions.
The proposed stacking ensemble model incorporated the Multiple Instance Self-Training (MIST) score derived from WSIs, patient sex, and tumor location (colon vs. rectum). Base learners included logistic regression, XGBoost, and random forest, with a meta-learner synthesizing their outputs to generate the final LNM prediction. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) in both internal and external cohorts.

Results

LNM was observed in 69 (11.6%) training cases, 15 (15.0%) test cases, and 2 (8.0%) external validation cases. The model achieved an AUC of 0.6965 in the internal test cohort and 0.7500 in the external validation cohort, demonstrating stable and generalizable predictive performance.
A representative case involved a 64-year-old man with a 16-mm type 0-Is lesion in the sigmoid colon resected via endoscopic mucosal resection (EMR). Histopathology showed well-differentiated tubular adenocarcinoma (tub1 > tub2), submucosal invasion depth of 3,300 µm (T1b), tumor budding grade BD1, Ly0, V1a, and negative resection margins (HM0, VM0). Despite guideline-based recommendations prompting additional surgical resection, no LNM was found (N0, 0/16), and the patient remained recurrence-free five years postoperatively—consistent with the AI model’s prediction.

Conclusion

The stacking-based AI model exhibited robust and generalizable performance in predicting LNM in T1 CRC, both internally and across external institutions. This approach offers a complementary tool to conventional pathology and may enhance individualized decision-making regarding the necessity of additional surgical intervention.

Introduction

The lymphocyte-to-monocyte ratio (LMR) is widely utilized as a surrogate marker of systemic inflammation and is increasingly recognized as an indicator of immune status within the tumor microenvironment, particularly in the setting of cancer immunotherapy.

Aims & Methods

^​​​​​This study aimed to evaluate the prognostic relevance of LMR in patients undergoing combination therapy with durvalumab (Dur) and tremelimumab (Tre) for unresectable hepatocellular carcinoma (uHCC). A total of 242 patients with uHCC who received Dur/Tre therapy at multiple institutions between February 2023 and March 2025 were retrospectively analyzed. Inclusion criteria encompassed available baseline LMR, Child-Pugh class A liver function, and complete clinical data. Patient characteristics were as follows: median age 74.0 years (IQR: 68.3–77.0); sex distribution, 202 males and 40 females; performance status (PS) 0/1/≥2: 201/32/9; underlying liver disease (HBV/HCV/HBV+HCV/NBNC): 37/72/1/132; BCLC stage (≤A/B/≥C): 19/68/155; Child-Pugh score (5/6): 125/117; alpha-fetoprotein (AFP) level: 57.6 ng/mL (IQR: 4.3–909.8); LMR: 3.14 (2.18–4.15); treatment line (first-/second-line): 94/148; and median observation period: 9.0 months (5.0–14.2).

Results

The median progression-free survival (PFS) and overall survival (OS) were 3.5 months (2.8–4.3) and 19.2 months (15.4–NA), respectively. Time-dependent ROC analysis identified 2.15 as the optimal LMR cutoff at 25% of the observation period (15.4 months). Objective response rates per RECIST version 1.1 were as follows: complete response (CR), 3.2%; partial response (PR), 15.5%; stable disease (SD), 32.4%; and progressive disease (PD), 48.9%. Disease control rate (DCR) was significantly higher in the LMR ≥2.15 group compared to the <2.15 group (55.4% vs. 37.3%, p = 0.026). Patients with LMR ≥2.15 demonstrated significantly longer PFS (3.8 months [95% CI: 3.8–4.6] vs. 2.7 months [95% CI: 2.00–4.00]; p= 0.005) and OS (NA months [95% CI NA: –17.9] vs. 13.2 months [95% CI: 8.5–17.1]; p = 0.005). In multivariate analysis using the Cox proportional hazards model, LMR ≥2.15 emerged as an independent predictor of both PFS (HR = 0.622; 95% CI: 0.438–0.884; p = 0.008) and OS (HR = 0.558; 95% CI: 0.328–0.949; p = 0.031). Hazard ratio approximation curves indicated that the range of LMR associated with significant prognostic impact on both PFS and OS was approximately 1.6 to 2.4. Subgroup analysis further demonstrated that in first-line treatment settings, patients with LMR ≥2.15 had superior PFS and OS outcomes compared to those with LMR <2.15 (PFS: p = 0.028; OS: p = 0.016).

Conclusion

​​​​LMR serves as a valuable prognostic biomarker in patients receiving Dur/Tre combination therapy for uHCC, with potential utility in guiding therapeutic decision-making.

Disclosure

Toshifumi Tada: lecture fees from AbbVie, Eisai, and Chugai
Atsushi Hiraoka: lecture fees from Eisai, Bayer, Eli Lilly, and Otsuka
Hidenori Toyoda: lecture fees from AbbVie, Eisai, Gilead, Terumo, and Bayer

Introduction

The management of malignant hilar biliary obstruction can be done by endoscopic biliary stenting, which is a well-established palliative treatment, improving the quality of life by relieving symptoms.

Aims & Methods

This systematic review and meta-analysis aimed to compare the use of stents placed above and across the sphincter of Oddi in patients with malignant hilar biliary obstruction. We performed a systematic search of the PubMed, Embase, and Cochrane Library databases in April 2025. Article screening was conducted independently by two authors using Rayyan software. Inclusion criteria were randomized controlled trials (RCTs) comparing stent placement above and across the sphincter of Oddi for malignant hilar biliary obstruction, evaluating at least one of the outcomes of interest. The outcomes were stent migration, stent patency, cholangitis, stent occlusion, and successful placement of the stent. RStudio software was used for statistical analysis, applying a random-effects model to calculate the risk ratio (RR) in binary outcomes and mean differences (MD) in continuous outcomes.

Results

We included three RCTs comprising 161 patients. There was no significant difference between the transpapillary and suprapapillary stents regarding the rates of stent migration (RR 2.03; 95% CI 0.41–10.16; p=0.39; I²=55%), cholangitis (RR 0.65; 95% CI 0.08–5.07; p=0.68; I²=0%), technical success (RR 0.99; 95% CI 0.95–1.04; p=0.80; I²=0%), and stent occlusion (MD 89.20; 95% CI 16.30–162.10; p=0.02; I²=78%). However, the mean number of patent stents was significantly lower in the suprapapillary stent group.

Conclusion

The two types of stent seem similar in terms of technique, efficacy, and safety, although the suprapapillary stent seems superior in terms of stent patency.

References

Ko SW, Joo HD, Song TJ, Kim S, Choi SJ, Oh CH, Oh D, Park JS, Yoon SB, Yoon JH, Seo DW, Lee SK. Impact of the suprapapillary method on patency in distal malignant biliary obstruction: a multicenter randomized controlled trial. Gastrointest Endosc. 2024 Oct;100(4):679-687.e1. doi: 10.1016/j.gie.2024.03.024. Epub 2024 Mar 21. PMID: 38521477.
Kurita A, Uza N, Asada M, Yoshimura K, Takemura T, Yazumi S, Kodama Y, Seno H. Stent placement above the sphincter of Oddi is a useful option for patients with inoperable malignant hilar biliary obstruction. Surg Endosc. 2022 May;36(5):2869-2878. doi: 10.1007/s00464-021-08576-x. Epub 2021 Jun 2. PMID: 34076770.
Finn Møller Pedersen, MD, Annmarie Touborg Lassen, Ove B. Schaffalitzky de Muckadell. Finn Møller Pedersen, MD, Annmarie Touborg Lassen, Ove B. Schaffalitzky de Muckadell. Gastroint Endosc. 1998;48(6):574-579.