Introduction

EUS-guided transmural drainage and subsequent interventions (e.g., endoscopic necrosectomy [EN]) are increasingly utilized for walled-off necrosis (WON). Few studies have examined the safety and effectiveness of EUS-guided treatment of WON according to the timing of subsequent EN.

Aims & Methods

We conducted a retrospective cohort study within the WONDERFUL (WON anD pERipancreatic FlUid coLlection) consortium, which consisted of expert endoscopists, gastroenterologists, interventional radiologists, and epidemiologists at eleven high-volume centers in Japan (UMIN CTR registration number, UMIN000044130). We included 222 patients who received EUS-guided transmural drainage for WON between January 2010 and November 2020. We excluded cases where no step-up treatment was required. We categorized the treatment strategies into early EN (< 14 days of the initial drainage), delayed EN (14-28 days), and drainage-oriented step-up approach (non-EN), and examined clinical outcomes (time to clinical success and adverse events [AEs]) by the timing of EN. Clinical success was defined as a reduction in the WON size to < 2 cm or the removal of all transmural stents and catheters along with the relief of the associated symptoms.

Results

Among the 222 patients, 63, 24, and 51 patients received early EN, delayed EN, and non-EN, respectively. The non-EN group was characterized by a higher rate of multi-locular collection (75% compared to 45% and 54% in the early and delayed EN groups, respectively; P = 0.005). The delayed EN group was characterized by a lower rate of WON extension to the pelvic cavity (8.3% compared to 32% and 35% in the early and non-EN groups, respectively; P = 0.045). Despite comparable overall rates of clinical success within 180 days between the groups, the conduct of EN was associated with early resolution of WON compared to non-EN with median times to clinical success of 62 days vs. 92 days, respectively (P = 0.043). No statistically significant difference was observed between the early and delayed EN groups (68 days vs. 55 days, P = 0.043). The number of endoscopic interventions was larger in the EN group than in the non-EN groups (median, 7 vs. 4.5 vs. 3 for early EN, delayed EN, and non-EN, respectively; P < 0.001). Early EN was associated with a higher rate of procedure-related AEs compared to delayed EN and non-EN (25.4% vs. 8.3% vs. 11.8%, respectively; P =0.070).

Conclusion

The EN-based step-up approach might be associated with a shorter time to clinical success in WON treatment compared to the drainage-oriented treatment. The treatment strategy for this population should be optimized based on further research on the optimal timing of EN initiation as well as the safety of EN.

References

1) Banks PA, Bollen TL, Dervenis C et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102-111
2) Baron TH, DiMaio CJ, Wang AY et al. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology 2020; 158: 67-75.e61
3) Isayama H, Nakai Y, Rerknimitr R et al. Asian consensus statements on endoscopic management of walled-off necrosis. Part 2: Endoscopic management. J Gastroenterol Hepatol 2016; 31: 1555-1565
4) Yasuda I, Nakashima M, Iwai T et al. Japanese multicenter experience of endoscopic necrosectomy for infected walled-off pancreatic necrosis: The JENIPaN study. Endoscopy 2013; 45: 627-634

Disclosure

Y.N. received research grants from Boston Scientific Japan, HOYA Corporation, and honoraria from Boston Scientific Japan, Fujifilm Corporation, Olympus Corporation. H.I. received research grants from Boston Scientific Japan, Fujifilm Corporation, Fujifilm Health Care Corporation, Gadelius Medical KK, Zeon Medical Inc., and honoraria from Boston Scientific Japan, Fujifilm Corporation, Taewoong Medical Devices, Olympus Corporation, Century Medical,Inc. and Cook Medical Japan G.K. Y.I. received honoraria from Gadelius Medical KK and Medicos Hirata.

Introduction

Pancreatic steatosis (PS) has been increasingly recognized and associated with some relevant metabolic implications. However, data on its correlation with exocrine pancreatic function remain limited. We conducted a systematic review and meta-analysis to evaluate whether PS is associated with exocrine pancreatic insufficiency (EPI).

Aims & Methods

This study aimed to investigate whether imaging-detected PS is related to exocrine pancreatic dysfunction, assessed by fecal elastase-1 (FE-1) levels. We searched PubMed, EMBASE, and Cochrane Central for studies including adults with and without PS identified on imaging, and reporting FE-1 concentrations. Data were pooled using random-effects models.

Results

Three studies evaluating a total of 1,864 patients were included. Fecal elastase levels were significantly lower in patients with PS compared to controls, indicating worse exocrine pancreatic function in this group (MD -199.78; 95% CI -303.66 to -95.91; p < 0.05; I² = 97%). Moreover, PS was associated with a significantly increased risk of exocrine pancreatic insufficiency (RR 3.13; 95% CI 1.17–8.40; p = 0.023; I² = 81%), reinforcing the link between fat accumulation in the pancreas and impaired exocrine function.

Conclusion

This meta-analysis demonstrates a significant association between PS and impaired pancreatic exocrine function, compared to individuals without known pancreas disease. These findings underscore the importance of a comprehensive metabolic assessment in patients with PS, given its potential role in pancreatic dysfunction.

Introduction

Pancreatic neuroendocrine tumors (pNETs) are a heterogeneous group of tumors with different treatment options depending on pathological grading, clinical staging, and presence of symptoms related to hormonal secretion. Their classification is made on mitotic count and Ki-67 index.
The current standard for Grading assessment is analysing the material obtained from EUS-guided fine needle aspiration/biopsy (EUS-FNA/FNB). However this technique is not free from adverse events and could be challenging for NETs localization.
The evidence of high grade of fibrosis and microvascular density decrease (MVD) on tumor pathological specimens has led many authors to search for undirected malignant features of pNET extrapolated from non-invasive techniques. The introduction of ancillary techniques, such as second-generation contrast agents (CH-EUS), has improved study of pNET. Particularly, at CH-EUS examination contrast pattern well correlates with behaviour and grading of NETs. However, the use of contrast agents entails a prolongation of procedure time and additional costs. An innovative ultrasound Doppler technique, Detective Flow Imaging EUS (DFI-EUS), involves no additional time or cost as it doesn’t require the administration of contrast agent. There is still no standardisation of this technique and few studies have validated its use.

Aims & Methods

The aim of this study is to evaluate the DFI role in defining NET vascularization and its correlation with CH-EUS. The second aim of the study is to assess DFI role in predicting histological grading.
Single center retrospective analysis on consecutive patients with solid pancreatic lesions who underwent EUS at Therapeutic Digestive Endoscopy Unit of the Fondazione Policlinico Universitario Campus Bio-Medico in Rome.
After activation of DFI, each lesion was observed for at least 30 seconds. Lesions was classified into three grades, according to the degree of vascularisation at DFI: (grade 0 absence of microvascularization of the tumor; grade 1 minimal/isovascularization of the tumor; grade 2 markedly increased microvascularization).
All lesion with final hystological diagnosis of NET were enrolled.
Grading and Ki-67 index of tumors were reported.
Data about lesion’s features and procedure were collected.

Results

From April 2024 to February 2025, 17 patients were enrolled (58.8% male; mean age 57±12 years old). The majority of lesion (53%) were localized in the body of the pancreas and the mean lesion’ s size was 28±20 mm. The final histological diagnosis classified 50% lesions as G1, 38.8% G2 and 5.5% G3.
At the CEH-EUS the 70.6% of lesion showed hyper-enhancement. About the DFI evaluation the 17.6% of lesion was hypo-vascular, 17.6% Iso-vascular and 64.7% was hyper-vascular. There was excellent correlation between DFI characterization of the lesion and the CH-EUS (ICC 0.9)
Among the NET G1, 66.7% were Hypervascular at DFI and 33.3% Isovascular. Among the G2, 71.4% were Hypervascular at DFI and 28.6% Hypovascular. The only G3 lesion was Hypovascular.
There was inverse correlation between the NET grade and the DFI grade (Pearson coefficient -0.56; p 0.02).

Conclusion

DFI-EUS can provide a fast evaluation of the micro-vascularization of pNET with excellent correlation with CH-EUS. Hyper-vascular pattern at DFI correlates with low Ki-67 index.

Introduction

There are doubts about the effectiveness of concomitant use of probiotics (PB) in the treatment of Helicobacter pylori infection. Objective: To determine whether the use of PB improves the effectiveness of eradication treatments used in Europe.

Aims & Methods

Prospective, multicentre, non-interventional, prospective registry (Hp-EuReg) of the clinical practice of European gastroenterologists. Data were collected in an e-CRD in AEG-REDCap from 2013 to 2021. All data from countries with at least 30 cases undergoing eradication therapy and at least 1 with associated PB were included, using patients without PB as controls and grouping by geographical region. Modified intention-to-treat (mITT) analyses were performed, as well as multivariate analysis, assessing factors associated with treatment effectiveness.

Results

36,699 patients were included, 8,233 (22%) with PB. Overall, PB use was associated with greater effectiveness (91% vs 86%; p<0.0001). Adjusting for treatment regimen, this significance held for triple (89% vs 83%; p<0.0001), concomitant quadruple (93% vs 89%; p=0.0009), quadruple with bismuth (92% vs 86%; p<0.0001) and sequential (91% vs 78%; p<0.0001) therapies. In the logistic regression model in first-line eradication (adjusted for age, sex, duration of eradication treatment, PPI dose and adherence), PB use maintained the benefit in the triple, bismuth quadruple and sequential treatments. After adjusting such a model by region, significance was maintained in the Eastern region (low rate of resistance to clarithromycin and metronidazole) for triple therapies, and in the Central region (high rate of resistance) for concomitant quadruple and sequential therapies.

Conclusion

In Europe, the use of formulations with PB adjuvant to eradication therapy is associated with increased effectiveness of eradication therapy, with the benefit being superior in triple and sequential therapies.

Disclosure

Nothing to disclosure

Introduction

Surveillance colonoscopy in patients with Inflammatory Bowel Disease (IBD) poses a unique challenge due to the subtle nature of flat dysplasia. But this challenge is further compounded by the number of additional lesions seen as a result of inflammation, such as pseudo-polyps and inflammatory polyps which can result in additional biopsies or unnecessary resection. Computer aided diagnosis (CADx) could improve lesion characterisation in this cohort of patients but a dedicated CADx algorithm has yet to be developed. Here we compare the performance of endoscopists and an existing generic colon CADx algorithm on lesion characterisation in IBD patients.

Aims & Methods

In phase 1, endoscopist performance on image based characterisation was assessed using still images of lesions in patients with IBD. Frames were taken in both white light imaging (WLI) and Image Enhancement (IE). Images were checked by an independent reviewer for the quality of images. Characterisation was then performed by 12 endoscopists (6 experts who regularly perform IBD surveillance and 6 non-expert) who categorised them as neoplastic (adenoma with low or high grade dysplasia) or non-neoplastic (hyperplastic, regenerative, inflammatory or pseudo-polyps).

In phase 2, an existing generic colon CADx algorithm was used in video based analysis of prospectively collected IBD colonoscopy videos. Lesions were characterised as neoplastic or non-neoplastic. Ground truth in both phases was histology.

Results

In phase 1, 57 lesions (34 neoplastic, 23 non-neoplastic) were characterised by endoscopists. For non-experts, sensitivity, specificity and accuracy were 73.0%, 55.3% and 65.9% respectively on white light and 73.9%, 49.1% and 64.7% on IE. For expert endoscopists, sensitivity, specificity and accuracy were 70.1%, 66.7% and 68.7% respectively on WLI and 78.3%, 60.8% and 72.0% on IE.

In phase 2, full withdrawal videos in 20 patients undergoing surveillance colonoscopy were collected. 17 patients had Ulcerative Colitis, 3 patients had Crohn’s disease. 86 lesions were identified (21 neoplastic, 65 non-neoplastic). Video based CADx performance for sensitivity, specificity and accuracy was 88.89%, 80.64% and 74.44% respectively.

Conclusion

Our data highlights the challenges of lesion characterisation IBD patients, with a low sensitivity and specificity in both experts and non-experts. In particular, non-experts have a very low specificity meaning there may be a high number of unnecessary resections/biopsies performed. A generic CADx algorithm performed better than endoscopists and with dedicated training of this algorithm with IBD lesions could further improve characterisation and reduce the number of non-neoplastic lesions which are removed.

Disclosure

Professor Bhandari has received research grants or is the advisory board for Fujifilm, Boston, Olympus, Pentax, 3-D matrix, NEC (Japan), Medtronic

Introduction

The acid-suppressive drug such as proton pump inhibitor (PPI) is one of treatment options for functional dyspepsia (FD). However, the efficacy of potassium-competitive acid blockers(P-CABs) for treating FD is not established. This study aimed to assess the efficacy and safety of tegoprazan in patients with FD in a prospective, multicenter clinical trial.

Aims & Methods

Investigated FD was diagnosed using the Rome IV criteria. All patients received tegoprazan 50mg once daily for 8 weeks. Dyspeptic symptoms were assessed by a dyspepsia symptom questionnaire (5-point Likert scale, NDI-K, and GERD-HRQL). The main outcome was the rate of satisfactory relief of dyspeptic symptoms at 8weeks.

Results

A total of 173 patients were enrolled in this study. The rate of satisfactory relief of dyspeptic symptoms at 4 and 8weeks was 74.6% and 86.7%, respectively. The complete symptom relief rate at 4 and 8weeks was 15.0% and 24.9%, respectively. The symptom resolution rate was significantly higher at 8weeks than at 4weeks. (86.7% vs. 74.6%, p<0.001; 24.9% vs. 15.0%, p=0.003). The mean score of NDI-K and GERD-HRQL also significant decreased at 8weeks. The efficacy was not influenced by subtypes of FD or Helicobacter pylori status. There was no serious adverse event or death during the study.

Conclusion

Tegoprazan 50mg once daily significantly provides satisfactory symptom relief for FD. (International clinical trial registry number: KCT0005600)