Introduction

Pain in chronic pancreatitis (CP) varies between patients in pattern, severity, and psychological impact. CP pain assessment has been focused on intensity, missing the complexity. To address the importance of multidimensional pain evaluations, we aimed to identify pain phenotypes based on multidimensional pain assessments and examine their association with clinical factors.

Aims & Methods

We studied 248 patients with painful CP from Asia, Europe, and the USA. A cluster analysis was performed on patients with painful CP, including five pain dimensions from the COMPAT-SF questionnaire (severity, fluctuation, provocative factors, spreading pain, and qualitative descriptors). The resulting clusters were compared based on demographics and clinical data, including patient-reported outcomes and quantitative sensory testing.

Results

		Cluster 1	Cluster 2	Cluster 3	p-value​
Questionnaires	Quality of life	66.3 (22.5)	64.8 (27.7)	51.1 (24.6)	<0.001
	Catastrophizing	10.7 (11.2)	19.1 (12.4)	24.3 (13.0)	<0.001
	Anxiety	5.3 (4.1)	6.2 (4.2)	8.7 (4.5)	<0.001
	Depression	4.3 (4.3)	5.5 (4.6)	7.3 (4.7)	<0.001
	Sleep	5.0 (3.5)	5.9 (3.8)	7.5 (4.5)	<0.001
QST	PPDT sum, kPa	2284 (997)	1811.5 (574.6)	1640.1 (600.4)	<0.001
	PPTT sum, kPa	2909.6 (1247.3)	2227.1 (691.3)	2184.9 (903.2)	<0.001
	Temporal summation, abdomen	1.7 (1.8)	1.9 (1.5)	1.4 (1.8)	0.178
	CPM (%)	2.3 (18.3)	5.1 (23.7)	7.2 (17.7)	0.135

Three distinct pain phenotypes were identified in the cluster analysis. Cluster 1 (n=73) included patients with low-severity pain; Cluster 2 (n=80) was characterized by severe, fluctuating pain; and Cluster 3 (n=95) comprised patients reporting constant, severe pain. Patients in Clusters 1 and 2 reported low scores across the remaining dimensions, whereas Cluster 3 consistently scored higher. Quality of life and sleep were best in Cluster 1, declined in Cluster 2, and were lowest in Cluster 3 (both p<0.001). Scores for anxiety, depression, and catastrophizing increased progressively across clusters (all p<0.001). Sensory testing revealed a pattern of increasing hyperalgesia, with Cluster 3 showing the most pronounced responses (p<0.001).

Conclusion

The COMPAT-SF questionnaire identifies three pain phenotypes in CP. Greater pain severity and persistence correlate with increased hyperalgesia, higher psychological distress, and worse overall well-being.

Introduction

Cardiovascular diseases (CVDs) are often a limiting factor in cancer treatment. In our systematic review and meta-analysis we evaluated the prevalence and incidence of CVDs in pancreatic ductal adenocarcinoma (PDAC).

Aims & Methods

We conducted the systematic search on 5 February 2024 in three databases (PubMed, EMBASE, CENTRAL). Studies reporting the prevalence or incidence of CVDs in PDAC were included. Subgroup analyses based on cancer stage and treatment type were performed. Pooled proportions with the 95% confidence interval (CI) were calculated using a random effect model. We evaluated the risk of bias using the Joanna Briggs Institute Prevalence Critical Appraisal. (PROSPERO CRD42023482295).

Results

We included 198 articles. The prevalence of CVDs other than thrombotic events at PDAC diagnosis was similar to the one in the general population: hypertension 33 % (95%CI:27-40%), ischemic heart disease 6% (95%CI:3-12%), heart failure, arrhythmia, and stroke affecting each 2-3% of cases. Their incidence during treatment was low (1%-10% overall). Thrombotic events other than embolism affected 11% (95%CI: 7%-18%) of cases at diagnosis and the incidence during treatment was between 8-10% regardless of cancer stage or treatment type. Pulmonary embolism affected 3% of cases at diagnosis and occurred in a similar proportion during treatment. The included studies had an overall low-moderate risk of bias.

Conclusion

Thrombotic events affect around 10% of PDAC patients at baseline. A similar proportion develop thrombotic events during follow-up regardless of disease stage or treatment type. The prevalence of CVDs other than thrombotic events is equivalent to the one in the general population.

Introduction

Indeterminate biliary strictures pose a significant diagnostic challenge, as they can result from a wide spectrum of both benign and malignant conditions. Differentiating between these is crucial due to different management strategies. Conventional methods like endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology have limited sensitivity, often leading to repeated procedures and delays in treatment. Peroral cholangioscopy (POC) offers direct bile duct visualization and targeted biopsies, improving diagnostic accuracy. Modern systems, like the SpyGlass™ DS, enhance procedure feasibility and image quality.

Aims & Methods

Aims: The aim of our study is to assess the effectiveness of single-operator peroral cholangioscopy system (POCS) with its digital version SpyGlass^TM Direct Visualization System with SpyBite biopsies as a promising modality for accurate diagnosis of biliary strictures.
Method: We performed a two-center retrospective analysis of prospective database from March 2019 to March 2025. Each patient underwent peroral cholangioscopy using SpyGlass^TM Direct Visualization System with SpyBite biopsies for the diagnosis of indeterminate biliary strictures.

Results

We identified 162 patients who underwent peroral cholangioscopy during the study period (96 males and 66 females). The medium age of the patients was 63.04 years. There was 100 % technical success of the procedure. All patients underwent POCS due to indeterminate biliary strictures. Before the procedure CT scan was performed and positive for biliary stenosis in 115 (70.9%) of the cases. The biliary stenoses were located as follows: 20 (12.3%) in the distal common bile duct, 29 (17.9%) in the proximal common bile duct, 102 (62.9%) at the hepatic hilum and 11 (6.7%) in the intrahepatic bile ducts.
Benign disease was diagnosed in 39 (24.07 %) of the patients. Visual impression for malignant desease (at least one of the following- tortuous dilated vessels, friability and easily bleeding, infiltrative stricture, polipoid mass, nodular eleveted lesion, vegetative mass, fish-egg lesion, finger - like villiform lesion and irregular papillary or granular lesion) was found in 123 (75.9%) of the patients. The most reliable correlation with malignancy was found to be the presence of infiltrative strictures - 113 (69.7%) patients. A final diagnosis of cholagiocarinoma was established in 84
(51.8%) of them. In 39 (24.07%) patients, no tumor cells were found in the specimen. Visual impression accuracy with SpyGlass was 100% (with 100% sensitivity and 100% specificity). SpyBite biopsies accuracy was 69.05 % (with 68. 3% sensitivity and 100% specificity).

Conclusion

POC has proven valuable in evaluating indeterminate biliary strictures, offering advantages over ERCP by allowing real-time visualization and targeted biopsies. Our study supports POC's superior accuracy, especially in identifying malignant lesions, with visual impression achieving up to 100% sensitivity and specificity. However, POC adoption is limited by operator expertise, the need for standardized interpretation, and availability. While adverse events are rare (<10%), careful patient selection is essential. In conclusion, POC holds substantial promise as a key diagnostic tool for indeterminate biliary strictures, with ongoing improvements enhancing its clinical role.

Disclosure

No conflict of interest

Introduction

Endoscopic submucosal dissection (ESD) demands a high level of endoscopic skill and extensive training, even for experienced endoscopists, with a particularly steep learning curve for colonic ESD. Over the last three years, the French Society of Digestive Endoscopy (SFED) has implemented a structured ESD training program. This study aimed to evaluate the effectiveness of the SFED ESD training program to achieve competency in ESD and to identify factors associated with it.

Aims & Methods

Participants who attended the SFED ESD training curriculum over the past three years were invited to join the study. After completing a standardized initial simulation training week, each participant was asked to document each ESD procedures performed in their training center, along with technical details for each (lesion size and location, en bloc resection, R0 resection status, and procedural complications). Additionally, participants completed an online survey to gather information about their practice environment, ongoing ESD activity, and demographic data (e.g., gender, age, prior endoscopy experience). Successful dissection was defined as en-bloc resection with free lateral and deep margins (R0) and no need for surgical intervention due to complications. The performance threshold for achieving proficiency in ESD was defined, in line with ESGE guidelines, as achieving an en-bloc resection rate of >90% and a complication-related surgery rate of <1%. The learning curve to reach these competence standards was assessed using the LC-CUSUM method.

Results

A total of 45 students participated in the study. The majority were men (70%), with a median age of 36 years. They practice endoscopy for 6 years (IQR 4-10) and 82% performed interventional endoscopy (ERCP and EUS).
A total of 2,068 ESD procedures were performed by the trainees. The median number of ESDs conducted post-training was 34 (IQR 22-66), with the majority being colorectal (42.9% rectal and 42.7% colonic). Lesions had a median size of 45 mm (IQR 34-60), with a resection speed of 17.4 mm²/min (IQR 10.5-26.5). En bloc resection and R0 resection were achieved in 93.6% and 85.8% of cases, respectively, with a surgical complication rate of 0.94%. The overall success rate of ESD procedures was 92.7%. Success was more likely in rectal (97%) than colonic (90.4%) procedures. 75% of the students were competent. Among those who reached competence, the median number of ESDs required was 45. Factors associated with competency were : ESD localization (rectum > colon), the age (HR 0.92 [0.86-0.99]; p = 0.03) and experience (HR 0.91 [0.84-0.99]; p = 0.03) were inversely correlated to the competency. Practiced in a high volume ESD center (>100 ESD/year) lead to reach competency faster (p =0.008).

Conclusion

This study provides the first assessment of the SFED ESD training program in France. Competence in ESD is reachable after appropriate training. A big experience is not needed to attempt ESD. Supervised training is essential, and seems easier in a high-volume center to achieve competence more quickly. These findings may help inform the selection of future candidates for ESD training to ensure effective skill acquisition and safe practice.

Disclosure

nothing to disclose

Clinical Case Summary

Necrotizing pancreatitis, which is associated with an 8 to 39% rate of death, develops in approximately 20% of patients. One of its rare complications is the formation of pancreatic pseudoaneurysms, which can result in life-threatening gastrointestinal bleeding. Pancreatic pseudoaneurysm is a rare but potentially life-threatening vascular complication of chronic or necrotizing pancreatitis (4% to 17%). In this case, we describe the successful management of a pancreatic pseudoaneurysm in a patient with necrotizing pancreatitis using mesenteric angiography and embolization. This case report presents the management of a 57-year-old male with a history of hypertension & dyslipidemia with good functional capacity and health seeking behavior. He had no other significant medical, family, and psycho-social history. The patient came in for severe epigastric pain radiating to the back and was initially managed as a case of gallstone pancreatitis. Weeks later he developed overt gastrointestinal bleed (melena). Further work up revealed progression to necrotizing pancreatitis with subsequent pancreaticoduodenal fistula and hemorrhagic complications seen on imaging and esophagogastroduodenoscopy. He underwent successful mesenteric angiography with coil embolization; however, the fistula persisted, draining necrotic fluid and delaying the initiation of oral feeding. To promote fistula healing, an endoscopically placed nasoduodenal tube was advanced to the fourth part of the duodenum, allowing enteral nutrition while bypassing the second part of the duodenum. This case highlights the clinical presentation, diagnostic imaging, interventional techniques, and the multidisciplinary approach essential for effective management.

References

[1] Yang Y, Liu XM, Li HP, Xie R, Tuo BG, Wu HC. Pancreatic pseudoaneurysm mimicking pancreatic tumor: A case report and review of literature. World J Gastrointest Oncol 2023; 15(11): 2041-2048 [PMID: 38077637 DOI: 10.4251/wjgo.v15.i11.2041]
[2] Tessier DJ, Stone WM, Fowl RJ, et al. Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature. J Vasc Surg. 2003;38(5):969–974. [published Online First: 2003/11/07].
[3] Flati G, Andren-Sandberg A, La Pinta M, et al. Potentially fatal bleeding in acute pancreatitis: pathophysiology, prevention and treatment. Pancreas 2003;26:8–14
[4] Butturini G, Daskalaki D, Molinari E, Scopelliti F, Casarotto A, Bassi C. Pancreatic fistula: definition and current problems. J Hepatobiliary Pancreat Surg. 2008;15(3):247-51. [PubMed]
[5] Morgan KA, Adams DB. Management of internal and external pancreatic fistulas. Surg Clin North Am. 2007 Dec;87(6):1503-13, x. [PubMed]
[6] Systematic management of postoperative enterocutaneous fistulas: factors related to outcomes. Martinez JL, Luque-de-Leon E, Mier J, Blanco-Benavides R, Robledo F; World J Surg. 2008;32(3):436.
[7] Visschers, R. G., van Gemert, W. G., Winkens, B., Soeters, P. B., & Olde Damink, S. W. (n.d.). Guided treatment improves outcome of patients with enterocutaneous fistulas.

Introduction

The Mayo Endoscopic Subscore (MES) is widely used in clinical trials and daily practice to assess disease activity and response to treatment in UC.

Aims & Methods

The objective of this study was to identify any nuances in patients with MES > 1 treated with non-TNF biologics and targeted oral therapies. The Ipsos UC Therapy Monitor, a multi-centre online medical chart review study of patients with UC, was conducted between July and September 2024 among gastroenterologists practicing across hospital and private practices in the UK, France, Germany, Italy, and Spain. Physicians were screened for practice duration and patient volume. Charts of patients prescribed advanced therapy were included in the analysis.

Results

205 sampled physicians collectively reported 820 UC patients. Of the reported patients with MES > 1, 62 were treated with non-TNF biologics and 62 were treated with novel oral therapies. Among the patients treated with non-TNF biologics, a higher proportion were female vs those receiving oral therapy (48% vs 31%); they were also older in age (mean years: 43 vs 38).
The patients treated with non-TNF biologics had a higher prevalence of comorbidities, including depression/anxiety (24% vs 19%), cardiovascular disease (8% vs 0%), and dyslipidemia/hyperlipidemia/hypercholesterolemia (11% vs 7%), compared to those treated with novel oral therapy.
Mean CRP levels were higher in the oral therapy group (10.2 mg/L vs 9.1 mg/L), while mean Mayo scores were slightly lower (4.7 vs 5.2). Fecal calprotectin levels were elevated in patients treated with non-TNF biologics vs oral therapy group (441 µg/g vs 503 µg/g).
When analysing reasons for prescribing selected advanced therapy between the two patient groups, a greater proportion of patients treated with non-TNF biologics had safety reasons specified more frequently by the sampled physicians.

Table 1: % of reported UC patients receiving advanced therapy for specific cited reasons

% reported UC patients - cited reasons	Patients treated with non-TNF biologics	Patients treated with novel oral therapies
Low incidence of side effects	53%	13%
Good safety profile	61%	16%
Rapid symptomatic profile	19%	60%

Conclusion

This study highlights key differences in patient characteristics and treatment considerations among UC patients with MES > 1 treated with non-TNF biologics compared to those treated with targeted oral therapies. Patients on non-TNF biologics tend to be older, more often female, and have a higher prevalence of comorbidities. Physicians prescribing non-TNF biologics prioritize safety, while those prescribing oral therapies focus on rapid symptom control. These findings highlight the importance of considering patient characteristics and treatment goals when selecting advanced therapies for UC patients with MES > 1. Further investigation using comparator cohort is warranted.

Introduction

The Mayo Endoscopic Subscore (MES) is the most widely used endoscopic index for assessing disease activity in ulcerative colitis (UC). Although artificial-intelligence　(AI)–assisted colonoscopy is expected to reduce inter-observer variability, the MES 4-point scale (0–3) lacks sufficient sensitivity to detect subtle changes in mucosal activity, limiting its ability to capture incremental improvement or deterioration. Moreover, because MES focuses on qualitative features—such as bleeding and erosions—without considering the extent or surface area of inflammation, it provides an incomplete estimate of a patient’s overall inflammatory burden.

Aims & Methods

We sought to develop and validate a quantitative, AI–driven colonoscopic score—Quantitative Ulcerative Colitis Assessment using Deep-learning (QUAD)—and to determine whether it predicts clinical relapse in patients with UC. The QUAD system was trained on 84 743 colonoscopic images from 998 UC patients at three centers and comprises three main functions: i) Image filtering: Automatic exclusion of low-quality images that are unsuitable for analysis owing to light saturation (halation), inadequate insufflation, excessive proximity to the mucosa, chromoendoscopy, or virtual chromoendoscopy. ii) Frame-level scoring: Each frame is divided into four quadrants; inflammation in each quadrant is graded from 0 to 3, and the quadrant scores are summed to yield a QUAD score of 0–12. iii) Video-level aggregation: Full-length withdrawal videos are processed to generate (i) an Entire QUAD score (0–60), representing pan-colonic inflammation, and (ii) a Distal QUAD score (0–12) for the rectosigmoid segment (final 20 % of the video).
The QUAD system contains mainly three function: i) automatically exclude low quality images that is ineligible for analysis in cases of halation, inadequate air de­livery, proximity to mucosa, chromoendoscopy, and virtual chromoendoscopy; ii) fully auto­mated twelve-class score output based on frame analysis: Each frame was divided into four quadrants; inflammation in each quadrant was graded 0–3 and summed to yield a QUAD score of 0–12; and iii) full-length withdrawal videos were processed to generate (I) an Entire QUAD (0–60) for considering whole-colon inflammation status and (II) a Distal QUAD (0–12) for the distal rectum–sigmoid segment (final 20 % of the video). An open-label cohort of adults with quiescent UC (partial Mayo score ≤ 2 for ≥6 months) was prospectively enrolled at a single center (August 2022–February 2023), and followed for 24 months after baseline colonoscopy; clinical relapse was defined as partial Mayo score > 2. The predictive value of QUAD scores for relapse was evaluated.

Results

Frame-level QUAD scores correlated strongly with expert-assigned MES values (Spearman r = 0.68, p < 0.01). Among 156 participants (median age, 51 years; 49 % male), 22 experienced relapse during follow-up. Relapse occurred in 19.4 % (19/98) of patients with a QUAD score > 3 versus 5.2 % (3/58) with a score ≤ 3 (log-rank p = 0.01).
In video analysis, an Entire QUAD > 6 did not significantly stratify relapse risk (16.8 % [17/101] vs 9.1 % [5/55]; log-rank p = 0.17). In contrast, a Distal QUAD > 3 was strongly associated with relapse (43.8 % [7/16] vs 10.7 % [15/140]; log-rank p < 0.01).

Conclusion

AI-generated QUAD provides a sensitive, fully quantitative measure of mucosal inflammation and stratifies relapse risk in clinically quiescent UC. In particular, the automatically derived Distal QUAD—focused on the distal colon and independent of operator image selection—offers a practical, objective tool for longitudinal monitoring and treatment tailoring in UC.