Introduction

Endoscopic Vacuum Therapy (EVT) and Fully Covered Metal Stents (FC-SEMS) are standard treatments for anastomotic leaks (AL) following upper gastrointestinal (UGI) surgery^1-3. Recently, a new hybrid device combining an FC-SEMS with a polyurethane EVT sponge (VACStent) has been introduced, showing promising results⁴. However, there is not comparative data between VACStent and traditional endoscopic methods for ALs.

Aims & Methods

In this retrospective study, all patients with AL after UGI oncologic surgery who underwent EVT or VACStent at a tertiary academic center from March 2015 to September 2024 were included. The two endoscopic techniques were compared. The primary outcome was clinical success (CS), with secondary outcomes including number of devices used, treatment duration, and adverse events (AEs).

Results

Over 114 months, 103 patients [92 EVT, 11 VACStent] were enrolled. Of these, 74.8% had AL following Ivor-Lewis esophagectomy. The two cohorts did not differ significantly in terms of comorbidities, neoadjuvant treatment, leak number/median size, or rates of redo-surgery before endoscopic management. Both EVT and VACStent were used as first-line treatments in a similar rate of patients (79.3% vs. 90.9%, p=0.36).
The EVT group had a higher CS rate than the VACStent group, though this difference was not statistically significant (72.8% vs. 54.5%, p=0.21). Compared to the EVT group, the VACStent group required significantly fewer endoscopic sessions (1±0.7 vs. 3±2.5, p<0.001) and had a shorter mean treatment duration (12.1±11.2 vs. 14.1±12.9 days, p=0.62). Additionally, a significantly lower proportion of patients in the VACStent group required admission to the intensive care unit (ICU) (27.3% vs. 84.4%, p<0.001). In the EVT group, three adverse events were recorded (one bleeding episode and two sponge dislodgments), while no AEs were reported in the VACStent group (p=0.54) (Table 1).

Table 1 EVT vs ​VACStent: Outcomes

Conclusion

In this retrospective study, EVT and VACStent showed comparable success in treating post-UGI surgery leaks. VACStent was associated with a reduced need for ICU admission and fewer endoscopic sessions. Larger comparative data are warranted to define the role of VACStent in the treatment of leaks after UGI surgery.

References

1. Mandarino FV, Barchi A, Leone L, et al. Endoscopic vacuum therapy versus self-expandable metal stent for treatment of anastomotic leaks < 30 mm following oncologic Ivor-Lewis esophagectomy: a matched case-control study. Surg Endosc. 2023;37(9):7039-7050. doi:10.1007/s00464-023-10213-8
2. Mandarino FV, Barchi A, D'Amico F, et al. Endoscopic Vacuum Therapy (EVT) versus Self-Expandable Metal Stent (SEMS) for Anastomotic Leaks after Upper Gastrointestinal Surgery: Systematic Review and Meta-Analysis. Life (Basel). 2023;13(2):287. Published 2023 Jan 19. doi:10.3390/life13020287
3. Mandarino FV, Barchi A, Fanti L, et al. Endoscopic vacuum therapy for post-esophagectomy anastomotic dehiscence as rescue treatment: a single center case series. Esophagus. 2022;19(3):417-425. doi:10.1007/s10388-022-00912-x
4. Dell'Anna G, Fanti L, Fanizza J, et al. VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New "Kid on the Block" Who Marries the Best of Old Techniques-A Review. J Clin Med. 2024;13(13):3805. Published 2024 Jun 28. doi:10.3390/jcm13133805

Introduction

Quality assessment is a priority in the field of gastroenterology. However, limited data are available from Greece regarding adherence to quality standards in gastrointestinal endoscopy.

Aims & Methods

This study aims at assessing the knowledge and compliance of Greek gastroenterologists with established quality standards for upper and lower digestive endoscopy, while exploring factors that may influence compliance.
​This prospective study recorded data on the quality of upper and lower digestive endoscopy performed in Greece from October 2024 to January 2025. All members of the Hellenic Society of Gastroenterology (n=668) were invited to participate via an electronic survey. The survey included a questionnaire designed specifically for this study, covering demographic and professional characteristics, as well as quality indicators for gastroscopy and colonoscopy.

Results

A total of 164 gastroenterologists participated (response rate 24.55%), of whom 107(65.24%) were male, and 102(62.2%) working in public or academic hospitals. The duration of gastroscopy was not recorded by 116(70.73%) participants, while 102(62.2%) systematically used photodocumentation. Most participants utilized the Prague and Los Angeles classifications 156(95.12%) and 159(96.95%) respectively. Additionally, 140(85.37%) followed the Seattle protocol, and 158(96.34%) conducted biopsies according to ESGE guidelines for precancerous gastric lesions. However, 83(50.61%) don’t use a registry for patients with Barrett’s esophagus. Complications were systematically recorded after gastroscopy by 103(62.8%) and after colonoscopy by 90(54.88%).
In colonoscopy, 149(90.85%) use the BBPS scale, and 158(96.34%) reported successful cecal intubation. Withdrawal times exceeded six minutes for 151(92.07%) participants. An adenoma detection rate of over 25% was achieved by 117(71.78%), while 103(62.8%) consistently used the Paris classification. Proper polypectomy techniques were employed by 111(67.68%), but 100(60.98%) recommended follow-up intervals shorter than guidelines suggest. Patient experience following gastroscopy and colonoscopy was not recorded by 126(76.83%) and 116(70.73%) participants, respectively. Overall, compliance with quality indicators for upper and lower digestive endoscopy was observed in 87(53.05%) and 75(45.73%) participants, respectively. Multivariate analysis revealed that 5-15 years of experience (p=0.05), the use of video recording (p=0.01) and use of high-resolution endoscopes (p<0.01) were associated with improved compliance with quality indicators of upper endoscopy. Whereas age above 55 (p<0.01), use of high-resolution endoscopes(p<0.01), use of video recording (p=0.02) and attendance of educational seminars relevant with quality in endoscopy (p=0.05) were associated with improved compliance with quality indicators of colonoscopy.

Conclusion

In this study, discrepancies were observed in the compliance of Greek endoscopists with endoscopic quality indicators, highlighting the need for further improvement. The systematic recording of these quality indicators is essential, underlining the important role of scientific societies in this process.

Clinical Case Summary

A 50-year-old man with known hypertension and hypothyroidism was recently diagnosed with AML. He presented with high-grade fever for one month. There were no gastrointestinal complaints, weight loss, or night sweats. Physical examination was unremarkable aside from fever (38.7°C); he was hemodynamically stable.
Initial labs revealed pancytopenia: hemoglobin 8.4 g/dL, WBC 1.2 × 10⁹/L, platelets 42 × 10⁹/L, and ANC 200/µL. Peripheral smear confirmed febrile neutropenia. He was started on intravenous broad-spectrum antibiotics. Due to persistent fever, a workup for occult infections was initiated. Blood and urine cultures were negative. Serum and BAL galactomannan were positive, suggesting possible invasive aspergillosis; liposomal amphotericin B was commenced.
Abdominal ultrasound revealed a bulky pancreas with heterogeneous echotexture. Contrast-enhanced CT showed a 2×3 cm heterogeneously enhancing lesion in the pancreatic tail. CA 19-9 was normal. EUS identified a hypoechoic.The main differentials considered included: Leukemic infiltration: due to AML background, Primary pancreatic malignancy: suggested by the imaging appearance, Invasive fungal infection: supported by positive galactomannan assays,Pancreatic tuberculosis: rare, but considered due to an endemic background.
FNAC showed granulomatous inflammation with caseation. GeneXpert MTB/RIF was positive for M. tuberculosis.
He was started on anti-tubercular therapy. Fever resolved within 10 days. Imaging at 3 months showed resolution of the mass. He completed a 6-month course uneventfully.
The presence of a discrete mass and lack of gastrointestinal symptoms complicated the diagnosis. FNAC with GeneXpert was key in confirming TB and ruling out other causes.

References

Pancreatic TB is a rare form of extrapulmonary tuberculosis, accounting for less than 5% of abdominal TB cases. It typically affects younger individuals and may be more prevalent in immunocompromised patients, including those with HIV or malignancy.

Clinically, pancreatic TB is a great mimicker. Common symptoms include fever, abdominal pain, weight loss, and night sweats. Jaundice may be seen if there is biliary involvement. Radiologically, it is difficult to distinguish from pancreatic cancer or pancreatitis. Masses may be solid or cystic and can involve any part of the pancreas.

EUS has emerged as a critical tool in evaluating pancreatic lesions. It allows for high-resolution imaging and real-time sampling via FNAC. Cytological examination may reveal granulomatous inflammation, although this is not pathognomonic. A definitive diagnosis often hinges on demonstration of acid-fast bacilli, culture, or PCR-based methods such as GeneXpert.

Our case highlights the importance of considering TB in the differential diagnosis of pancreatic masses, especially in endemic areas or immunocompromised patients. Early diagnosis via EUS-FNA and initiation of ATT can result in complete clinical and radiological recovery, sparing the patient from unnecessary surgical intervention.

Introduction

Liver elastography is one of the basic diagnostic tools in hepatology practice. The most widely used and most studied tool in the world is transient elastography (Fibroscan), however, this system is unevenly available in Slovakia. Shear-wave elastography is a more accessible method because it is built into standard ultrasound systems. However, the problem of shear-wave elastography remains the interpretation of its results, since the threshold values for significant fibrosis (SF) and advanced fibrosis (AF) are unique for each system.

Aims & Methods

To compare the results of transient elastography (TE) and point shear-wave elastography (pSWE) in a cohort of patients examined simultaneously with both systems and to determine the clinical benefit of pSWE in practice.
We examined all indicated patients over a 15-month period using both TE and pSWE (Hitachi Arietta V70). We recorded liver stiffness values in kPa, and baseline demographic and laboratory parameters. We used TE as the gold standard, with a threshold of >10 kPa for SF and >15 kPa for AF. We evaluated the accuracy of pSWE in predicting the detection of SF and AF. We used three models: the first one containing only pSWE values, and two logit models using pSWE together with common demographic and laboratory parameters. We identified the area under the curve (AUROC) and threshold values for each model and evaluated the probability of SF and AF according to these values.

Results

We examined 500 patients with a median age of 60 (IQR 48-69), male/female 214/286, with a SF rate of 30.8% and AF of 18.4%. The stiffness values according to TE and pSWE showed a highly significant correlation (rho=0.593, P<0.001). We found the accuracy of pSWE alone in predicting SF (AUROC=0.812), and AF (AUROC=0.839) with threshold values of SF>6.34 and AF>8.45 kPa. For values of pSWE<6.34, 6.34-8.45, and >8.45 kPa, the probability of SF was 11.1, 40.9, and 65.4% and AF was 5.0, 14.77, and 48.9%. We created two probability models (for P, range 0 to 1): ASTEL1 (N=369) that included pSWE, GGT, and platelets (AUROC SF=0.856, AUROC AF=0.908), and ASTEL2 (N=467) using pSWE, age, sex, AST/ALT, GGT (AUROC SF=0.857, AUROC AF=0.901). We set a threshold of P<0.33 to exclude SF and P>0.66 to confirm AF. At P<0.33, P=0.33-0.66, and P>0.66, SF was present in 15.6, 62, and 94.2% (ASTEL1) and 13.92, 50.7, and 86.8% (ASTEL2). At P<0.33, P=0.33-0.66 and P>0.66, AF was present in 5.6, 30, and 79.7% (ASTEL1) and in 4.4, 28, 73.68% (ASTEL2).

Conclusion

pSWE alone has an excellent negative predictive value (<6.34 kPa, 88.9-95%) in the diagnosis of SF and AF. Higher accuracy of positive prediction of SF (86.8-94.2%) and AF (73.7-79.7%) can be achieved by using one of two probability models (for P>0.66) combining SWE values with common demographic and laboratory parameters.