Introduction

Besides increasing adequacy, Rapid-on-Site Evaluation (ROSE) during Endoscopic Ultrasound (EUS) or Endoscopic Retrograde Cholangiopancreatography (ERCP) may have an impact on choices and timing of subsequent therapeutic procedures, yet unexplored.

Aims & Methods

We conducted a retrospective evaluation of a prospectively maintained database of a tertiary, academic centre with availability of ROSE and hybrid EUS-ERCP suites.
All consecutive patients referred for pathological confirmation of suspected malignancy and Jaundice or Gastric Outlet Obstruction (GOO) between Jan-2020 and Sep-2022 were included.

Results

Of 541 patients with underlying malignancy, 323 (59.7%) required same-session pathological confirmation (male: 54.5%; age 70 [62-77]; pancreatic cancer: 76.8%, cholangiocarcinoma 16.4%). ROSE adequacy was 98.9% for EUS and 50% for ERCP-guided sampling.
Amongst 302 patients with Jaundice, ERCP cannulation was successful in 83.7%, but final drainage was completed in 97.4% thanks to 37 EUS-CholedochoDuodenostomies and 5 EUS-HepaticoGastrostomies. Amongst 21 patients requiring GOO palliation, EUS-GastroEnterostomy was performed in 15 and duodenal stenting in 6. All 53 therapeutic EUS procedures occurred after adequate ROSE.
Amongst ERCP-guided placement of stents, the use of plastic stents was significantly higher amongst patients with inadequate ROSE (10/11 [90.9%] versus 14/240 [5.8%], p<0.0001, OR=161 [19-1352]).
Median hospital stay for diagnosis and palliation was 3 [2-7] days and median time to chemotherapy was 33 [24-47] days.

Conclusion

Nearly two-thirds of oncological candidates to endoscopic symptoms palliation requires contemporary pathological diagnosis. An adequate ROSE allows same-session state-of-the-art therapeutics standardly restricted to pathologically confirmed malignancies (e.g. uncovered SEMS or therapeutic EUS), potentially leading to shorter hospital stay and time to chemotherapy.

Introduction

Experimental data have shown increased expression of angiogenic factors in portal hypertension and disruption of endothelial integrity in small intestinal mucosal vessels that is possibly correlated with antigen translocation to the portal circulation. ZO-1 is a tight junction structural protein of the intestinal epithelium. Recent data revealed that ΖΟ-1 is also expressed by endothelial and mesenchymal cells and plays a dominant role in mucosal healing. Decreased ZO-1 expression may unsettle epithelial restorative capacity following mucosal damage and contribute to the impaired endothelial integrity and bacterial translocation.

Aims & Methods

We therefore aimed to assess changes in mucosal vascular density and evaluate intestinal vessel endothelial integrity in cirrhotic patients by assessing the immunohistochemical expression of ZO-1 in small intestinal biopsy samples. Sixty-three cirrhotic patients were enrolled (M/F:35/28, mean age ±SD: 62±13) during an 18-month period. Nine non-cirrhotic patients served as controls. Patients with current or recent alcohol consumption, porto-splenic vein thrombosis, non-cirrhotic portal hypertension, hepatocellular carcinoma, transjugular intrahepatic portosystemic shunt, chronic kidney disease, celiac disease, acute infection, or any other chronic intestinal disease were excluded. Small intestine biopsy samples were taken during endoscopy and endothelial ZO-1 expression was assessed by immunohistochemistry using the indirect streptavidin biotin peroxidase method. Mucosal vascular density was evaluated by counting the number of mucosal vessels per x20 optical field. Serum lipopolysaccharide-binding protein (LBP) levels were measured by ELISA.

Results

Thirty-four patients (54%) had compensated and 29(46%) had decompensated cirrhosis. Child-Turcotte-Pugh (CTP) classification was: A 46 (73%)/B 14 (22%)/ C 3 (5%). The mean MELD score was 10.5±3.7. Mean LBP levels were 7511.97±2868.90 μg/ml. The mean number of mucosal vessels per x20 optical field did not differ between cirrhotic patients and controls (3.7±1.1 vs 3.2±0.9, p=0.238) but patients with CTP-A class had increased number of mucosal vessels compared to controls (3.8±1.1 vs 3.2±0.9, p=0.048) and CTP-B class patients (3.8±1.1 vs 3.2±0.7, p=0.045). A negative correlation was observed between the number of mucosal vessels and CTP score (r: -0.428, p=0.016). In cirrhotic patients, ZO-1 immunostaining was detected in the whole perimeter of all counted vessels per optical field in only 10/63 (16.4%) samples. Loss of endothelial ZO-1 immunostaining in more than 50% of the vessel perimeter or total loss of ZO-1 in more than 50% of counted vessels was observed more frequently in cirrhotic patient samples (42/63, 66.6%) compared to controls (1/9, 11.1%, p=0.001). Mean (±SD) LBP levels were numerically, albeit not significantly, higher in patients with than without significant loss of ZO-1 endothelial expression (7801±3698 vs 6761±1032 μg/ml, p=0.342).

Conclusion

Cirrhotic patients show increased loss of small intestinal endothelial ZO-1 expression compared to control patients. Intestinal mucosal vessel number is increased in CTP-A patients compared to control and CTP-B patients. These findings are in agreement with novel theories proposing that mechanisms leading to bacterial translocation in cirrhosis are not confined to the small intestinal lumen and merit further investigation.

Introduction

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is an important diagnostic tool for suspected parenchymal lesions within the gastrointestinal tract and adjacent organs. However, the amount of literature on EUS-FNA for sampling focal liver lesions (FLLs) is limited.

Aims & Methods

This study aims at evaluating the safety and effectiveness of EUS-FNA in FLLs. Data from 88 patients who were diagnosed with FLLs by imaging and underwent EUS-FNA was reviewed in this retrospective study at the Second Affiliated Hospital of Soochow University and Ruijin Hospital of School of Medicine of Shanghai Jiao Tong University from 1 January 2017 to 31 August 2022.The EUS-FNA biopsy results were compared with the final diagnosis to evaluate the diagnostic value. Meanwhile, the relevant factors were analyzed to determine their influences on the EUS-FNA biopsy results.

Results

A final diagnosis was obtained (86 malignant and 2 benign) from the 88 cases. The overall diagnostic accuracy of EUS-FNA in FLLs was 93.18% (82／88; 95% confidence interval [CI ],87.9–98.5), with a sensitivity, specificity, positive predictive value, and negative predictive value of 93.02% (80／86; 95%CI, 87.6–98.4), 100% (2／2; 95%CI, 100–100), 100% (80／80; 95%CI, 100–100), and 25% (2／8; 95%CI, -5–55.0), respectively . The parameters related to lesion and procedure were not statistically significant between these two groups (p> 0.05) (Table 1). The number of puncture needles in the groups showed a statistically significant difference between multiple and single punctures (p = 0.001).

Conclusion

It is revealed in this study that EUS-FNA is a safe and excellent diagnostic method for FLLs with high accuracy.

Introduction

Gastroenterology is a medical specialty that includes several areas of study. Endoscopy occupies a central role in professional practice, whether in hospitals or in the private sector. The quality of initial training and the different needs of trainees are key to the quality of care delivered to the population. This study aims to assess endoscopic training experience during fellowship.

Aims & Methods

This is a cross-sectional, multicenter study conducted on gastroenterology residents practicing endoscopy and in the final phase of their curriculum (6th, 7th and 8th semesters). Postgraduated doctors have been excluded from the study. An electronic survey made by Google Forms and was sent nationwide on January 9, 2024. The survey consisted of 42 questions divided into 3 parts: The first part focused on the participants' socio-demographic data and their endoscopic experience, the second part focused on the quality of training of core endoscopic skills (cognitive and motor skills) during fellowship where a 5-point Likert scale was used to express residents' satisfaction with their skills, ranging from 1="very dissatisfied", 2="dissatisfied", 3="neither satisfied nor dissatisfied", 4="satisfied" and 5="very satisfied". The third part included questions in which participants expressed their needs and expectations for improving their training in endoscopy. A statistical analysis using the Student-t test and the Fisher’s exact test were performed. P values of <0.05 were considered statistically significant. Data were analyzed using Jamovi (Version 2.3).

Results

We were able to collect data from 56 respondents. Most were female residents n=40 (71.4) with a mean age of 29.2 ± 2.5 years. The majority of fellows started practicing EGD in their 4th semester (91.1%), and colonoscopy in their 6th semester (57%). On average, the fellows are supervised by 5 senior doctors, including 2 who practice interventional endoscopy. Furthermore, 37.5% of participants report performing approximately more than 100 EGDs, 14.2% more than 100 colonoscopies, 80.4% report that they have performed less than 20 endoscopic variceal ligation and 14.3% have performed more than 10 polypectomies. An average rating score of 3.34 (1= very dissatisfied; 5= very satisfied) concerning the quality of training and feedback on cognitive aspects of endoscopy was found and we reported greatest emphasis for Procedure indication/contraindication and least on Capsule endoscopy interpretation.
The quality of training in technical aspects of endoscopy was rated higher (average rating score of 3.5). We reported greatest emphasis for Withdrawal/mucosal inspection and least on Esophageal dilation.
A significant association between motor skills and cognitive skills was found with a p<0.001.
Finally, to improve their training, 87.5% of respondents considered simulation to be important/very important, 98.2% of respondents intend to complete their endoscopy training at the end of their curriculum, and 87.5% are prepared to finance such a project (median: 1000 USD [1000;3000]).

Conclusion

Despite a significant improvement in training sites and technical facilities, training in endoscopy in healthcare institutions does not yet provide all the cognitive and technical skills required to enable fellows to be fully autonomous. With the development of endoscopic procedures, it seems essential for fellows to be able to perform more standard endoscopic procedures such as polypectomy and mucosectomy by the end of their curriculum. This may involve introducing regular endoscopy conferences and simulation training as a part of the curriculum.

Introduction

Insulinomas are rare, functioning neuroendocrine neoplasms that cause non-ketotic hypoglycemia due to hyperinsulinism. Surgery is considered the gold-standard treatment, although endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has been recently described as a less invasive, efficient therapeutic option for these tumors. In this study, we aim to compare post-procedural outcomes of surgical resection versus EUS-RFA for pancreatic insulinomas.

Aims & Methods

All patients who underwent surgical resection or EUS-RFA for pancreatic insulinoma in our Institution were included in the study, and data from all procedures were retrospectively recorded and statistically analyzed. EUS-RFA was indicated for all subjects either unfit for surgery or unwilling to undergo surgical treatment. Patients’ baseline characteristics, location, size of insulinomas, procedural time, and intra- and postoperative outcomes were compared.

Results

From April 2012 to July 2022, 11 and 10 patients with pancreatic insulinoma underwent surgical resection and EUS-RFA, respectively. The median age was 65.5 (51-84) and 37 years (28-72, p<0.001) for the EUS-RFA and surgery cohorts, respectively. As a whole, 15 (71.4%) out of 21 were female. The median tumor size was 15mm (8-30) for the surgical group and 11mm (8-19) for the EUS-RFA group (p=0.17). The majority of the insulinomas were located in the pancreatic body (28.6%) and tail (28.6%), with no statistical difference between the two groups (p=0.16). Operative time was significantly longer in the surgical population (280min, 120-372) as compared to the endoscopic one (28min,18-40, p<0.001). Clinical success, defined as the normalization of glucose blood levels, was reached in all cases. The complication rate was significantly higher in the surgical group compared to the endoscopic group (7-63.6% vs 1-10%, p=0.01). Specifically, 7 patients in the surgical cohort developed a pancreatic fistula while one patient in the EUS-RFA population had self-limiting bleeding after the procedure. One patient of the surgical cohort underwent reoperation for an infected abdominal fluid collection.

Table 1. Characteristics of patients classified by treatments.

Conclusion

As compared to surgical resection, EUS-RFA for pancreatic insulinomas may be considered a safe and efficient treatment option with a shorter operative time and a lower rate of related complications. Prospective comparative studies are needed to ascertain the role of EUS-RFA as a treatment of choice for selected patients with pancreatic insulinoma.

References

Fahmawi Y, Mehta A, Abdalhadi H et al. Efficacy and safety of endoscopic ultrasound-guided radiofrequency ablation for management of pancreatic lesions: a systematic review and meta-analysis. Transl Gastroenterol Hepatol. 2022 Jul 25;7:30.
Zhao YP, Zhan HX, Zhang TP et al. Surgical management of patients with insulinomas: Result of 292 cases in a single institution. J Surg Oncol. 2011 Feb;103(2):169-74.