Introduction

For distal malignant biliary obstruction (dMBO) self-expandable metal stents (SEMS) have shown improved patency over plastic stents. Whilst initial data suggest that Covered versus Uncovered SEMS increase Time to Recurrent Biliary Obstruction (TRBO), no data is available for Fully-Covered (FC) versus Partially-Covered (PC) design.

Aims & Methods

Pubmed, Scopus and Cochrane databases were screened from inception to January 2023 for all studies describing adult patients with dMBO, treated by endoscopic placement of FC or PC-SEMS and describing Adverse Events (AEs), Recurrences or TRBO for the specific stent subpopulation. A random-effects meta-analysis was performed following PRISMA checklist, reporting outcomes as pooled proportions or means [95% confidence interval (95%CI)]. Sub-analyses restricted to 1) prospective studies, 2) unresectable diseases, 3) pancreatic cancers were pre-planned. Heterogeneity and Publication bias were explored through I² statistic and LFK index respectively. Standardized differences (d-values) were calculated between the two groups (CRD42023393965).

Results

From 1290 records, 62 studies (3327 patients with FC-SEMS and 2322 patients with PC-SEMS) were included.
Comparison of FC versus PC-SEMS showed negligible differences (d-values<0.1) in the rate of total AEs (12% vs. 9.9%) and all specific adverse events, including cholecystitis (2.5% vs. 2.6%).
In prospective studies, total recurrences were similar between FC-SEMS (21.5% [16.8-26.5], I²=72.5%) versus PC-SEMS (25.6% [20.6-30.9], I²=84.5%), despite small differences (0.117-d-values-0.215) in the rate of ingrowth (0.2% vs 2.8%) favouring FC-SEMS and migration (7% vs 4.3%) favouring PC-SEMS. These results were confirmed amongst unresectable diseases, with even a small difference in total recurrences (30.7% versus 25.9%) favouring PC-SEMS.
In prospective studies, TRBO was estimated to be longer for PC-SEMS (369 [290-449] days, I²=71.9%) versus FC-SEMS (219 [165-273] days, I²=93.3%; d-value=0.129 [small difference]), with consistent results in unresectable diseases.

Conclusion

FC-SEMS and PC-SEMS seem comparable in terms of AEs (including pancreatitis and cholecystitis) and recurrences, as migrations of FC-SEMS are compensated by ingrowths of PC-SEMS. Despite high heterogeneity and small standardized differences, PC-SEMS showed longer patency in prospective studies and amongst unresectable malignancies, potentially advising head-to-head comparison in this scenario.

References

FC-SEMS and PC-SEMS seem comparable in terms of AEs (including pancreatitis and cholecystitis) and recurrences, as migrations of FC-SEMS are compensated by ingrowths of PC-SEMS. Despite high heterogeneity and small standardized differences, PC-SEMS showed longer patency in prospective studies and amongst unresectable malignancies, potentially advising head-to-head comparison in this scenario.

Introduction

Gastrointestinal variceal bleeding is a serious complication of cirrhosis. Currently, no score has been validated to assess the prognosis of a bleeding episode in cirrhotic patients. The aim of our study was to evaluate the performance of the CAGIB score for recurrence and mortality following upper gastrointestinal bleeding in cirrhotic patients.

Aims & Methods

We conducted a retrospective study of cirrhotic patients hospitalized for upper gastrointestinal bleeding due to portal hypertension [2012-2022]. We calculated the scores CHILD-PUGH, MELD, MELD-Na, MELD 3.0, ALBI, ROCKALL, GBS, NLR and CAGIB, and compared their performance in terms of early recurrence (5-days) , short-term recurrence ( 6-weeks) and early mortality ( 6-weeks) through the study of ROC curves (SPSS software, P significant if <0.05).

Results

We included 105 patients with a mean age of 63 years and a sex ratio F/M=1.05. The origin of the bleeding was oesophageal varices rupture in 94.28% of cases and gastric varices rupture in 17.14%. Endoscopic treatment was performed in 96 patients, 90 of whom underwent band ligation of esophageal varices. Short-term recurrence was noted in 20% of patients. Early recurrence was noted in 3.8% of patients. Fourteen cases of early death were recorded. The CAGIB score was the best predictor of early recurrence (AUC=0.995, Sensibility=83.3%, Spécificity=99.6%, Odds Ratio=47, p<0.001) but it has a poor prognostic value for short-term recurrence (p=0,08). For early mortality, the CAGIB score performed better than the other scores (AUC=0.891) with a Sensibility=85.7% and Specificity=83.5% for predicting mortality from a cut-off ≥-4.648 with an OR=18.

Conclusion

The CAGIB score had the best predictive value for early recurrence and mortality following an episode of upper gastrointestinal bleeding due to portal hypertension in cirrhosis. We therefore propose it as an easy-to-calculate and reproducible tool, for a cut-off >-4.648.

Introduction

Liquid biopsy in patients with pancreatic ductal adenocarcinoma (PDAC) has been challenged by the limited information obtained from systemic circulation (SC). Circulating Tumour Cells (CTCs) in portal circulation (PC) are deemed to be biologically relevant and potentially carrying prognostic significance, despite mostly been evaluated during surgery.

Aims & Methods

This prospective, single-centre, interventional study enrolled PDAC patients to assess the feasibility and safety of EUS-guided transgastric and transhepatic Portal Vein sampling (EUS-PVS) for isolating, enumerating, and characterizing CTCs. PC and paired SC samples underwent microfluidic enrichment and dielectrophoretic (DEP) single-cell sorting based on immunostaining for epithelial and mesenchymal biomarkers. Targeted next-generation KRAS sequencing was performed on CTC subpopulations in a subset of patients.

Results

Between May 2022 and October 2023, 20 PDAC patients (25% metastatic) underwent EUS-PVS with 100% feasibility and safety. CTCs were isolated in all patients from both districts, but the total CTC concentration was significantly higher in PC compared to SC (8.1 [5.8-21.3] vs. 4.1 [2.3-6] / 7.5 ml of blood, p= 0.01), particularly for mesenchymal CTCs. No associations with baseline clinical variables or disease stage were observed. A subset of CTCs exhibited KRAS codon 12 mutations, undetected in paired white blood cells.

Conclusion

EUS-PVS is a feasible, safe, and effective method for portal blood sampling, supporting subsequent molecular investigations. Despite more sensitive enrichment modalities enhance the yield of peripheral CTCs evaluation, portal circulation remains more informative, especially for detecting epithelial-to-mesenchymal transition events. DEP single-cell sorting was feasible in all patients, providing libraries of viable cells with specific 100%-pure phenotypes, potentially suitable for downstream molecular applications.

Introduction

The COVID-19 pandemic negatively affected cancer patients’ care in many ways, including the timely diagnosis of malignancies.^1,2 Hepatocellular carcinoma is a tumor with well-defined risk factors that is potentially curable if detected in the early phase. Biannual ultrasound in high-risk patients has proven to be a valuable tool for accomplishing this goal and has therefore long been recommended.³ However, in Western countries, the reported adherence to surveillance protocols was low in pre-pandemic years.⁴ Since the declaration of the pandemic, primarily during the lockdown, but also in the post-lockdown period, many patients missed their regular check-ups, and physicians feared a further fall in surveillance adherence and a rise in the proportion of patients presenting with advanced disease.

Aims & Methods

The aim of this study was to assess whether the pandemic influenced the hepatocellular carcinoma (HCC) surveillance program. 350 patients (80.9% male, median age 66.9 years) treated at our Department between October 2010 and February 2023 due to newly diagnosed HCC were included in the analysis. The ongoing COVID-19 pandemic was declared in March 2020. Patients were divided into groups according to the time of HCC diagnosis (pre-pandemic and during the pandemic) and into surveillance and non-surveillance groups. Chi-square test was used to analyze the results. The level of statistical significance was set at p < 0.05.

Results

The number of newly diagnosed HCC cases was 28.4/year pre-pandemic and 27.7/year during the pandemic. There was no statistically significant difference between surveillance rates pre-pandemic (21.8%) and during the pandemic period (27.0%, P=0.385), nor in the proportion of patients that presented with symptomatic disease (P=0.314). During the pandemic, patients were more likely to be diagnosed in the potentially curative stage of the disease (BCLC 0 and BCLC A) (20.9% vs. 36.1%; OR 2.13, 95% CI:1.25-3.65; P=0.005).

Conclusion

Surprisingly, the pandemic did not influence HCC surveillance rates. Moreover, in this period, patients were more likely to be diagnosed in the potentially curative stage of the disease. Even though the benefits of HCC surveillance are well known and its implementation widely encouraged, the rates have been stably low over the last decade.

References

1. Englum BR, Prasad NK, Lake RE, Mayorga-Carlin M, Turner DJ, Siddiqui T et al. Impact of the COVID-19 pandemic on diagnosis of new cancers: A national multicenter study of the Veterans Affairs Healthcare System. Cancer. 2022 Mar 1;128(5):1048-1056.
2. Angelini M, Teglia F, Astolfi L, Casolari G, Boffetta P. Decrease of cancer diagnosis during COVID-19 pandemic: a systematic review and meta-analysis. Eur J Epidemiol. 2023 Jan;38(1):31-38.
3. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol. 2018 Jul;69(1):182-236.
4. Singal AG, Lampertico P, Nahon P. Epidemiology and surveillance for hepatocellular carcinoma: New trends. J Hepatol. 2020;72(2):250-261.

Disclosure

Authors have no conflict of interest to declare.

Introduction

In patients with upper gastrointestinal bleeding (UGIB), the European Society of Gastrointestinal Endoscopy (ESGE) recommends adopting the following definitions regarding the timing of upper GI endoscopy: urgent (6-12h), early (≤24h), and delayed (>24h) (1). There is no consensus definition of emergent endoscopy, but previous publications use the timeline of <6h (2).
Early endoscopy is associated with better outcomes, and guidelines suggest that it should be performed within this time frame (1).
Last ESGE guideline about variceal bleeding (VB) suggests performing urgent endoscopy in this context (3). This is based on a meta-analysis showing lower overall mortality when endoscopy was performed <12h compared to >12h (4). Surprisingly, ESGE concludes that the optimal timing in this setting is controversial due to a lack of high-level evidence. In fact, except for this study, all the others examining this aspect show that performing endoscopy before 12h does not provide benefits (5,6).

Aims & Methods

We aim to compare whether urgent endoscopy (6-12h) provides benefits to VB and explore predictors for mortality.
Methods: Retrospective analysis of a prospective registry of UGIB patients admitted to 'Virgen de las Nieves University Hospital' (2013-2020). VB was defined as that coming from gastric or esophageal varices. Endoscopy timings were defined according to ESGE: emergent (<6h), urgent (6-12h), early (≤24h) and delayed (>24h) (1).
Main outcomes were in-hospital (endoscopy therapy, transfusion, rebleeding, misbalance of chronic condition, hospital stay, and mortality) and delayed-6 months (bleeding, cardiovascular events, mortality). Statistical analysis was performed using SPSS.

Results

1459 UGIB patients were collected, 216 with VB.
Statistical differences in main outcomes are shown in Table 1 (each letter in the subscript denotes column proportions that do not differ significantly from each other). No differences were found for the other outcomes.

Timing (% patients)	<6h (39.7%)	6-12h (28.8%)	12-24h (17.4%)	24h (2.7%)	p
Endoscopy therapy	85.1% a	63.5% b	65.8% b	66.7% b	0.014
Misbalance of chronic condition	48.3% a	30.2% b	23.7% b	50% a	0.026
Rebleeding	22.1% a	7.9% b	7.9% b	16.7% a	0.037
In-hospital mortality	27.4% a	13.6% b	11.1% b	50% a	0.025

We also compared basal characteristics and found differences in MAP(ASH) score≥2 (92.3% vs. 66.7% vs. 77.4% vs. 75%; p=0.003) and GBS≥12 (69% vs. 44.4% vs. 52.6% vs. 83.3%; p= 0.011).
Independent risk factors for in-hospital mortality were MAP(ASH)≥2 (1.26, 95% CI 1.03-1.54), misbalance of chronic condition (OR 9.92, 95% CI 3.56-27.61, p=0.000), and rebleeding (OR 3.95, 95% CI 1.45-10.79, p=0.007). The timing of endoscopy performing was not an independent prognostic factor for mortality.
We also conducted subgroup analysis to assess whether performing endoscopy before 12h provides benefits in other UGIB patients, without finding differences for patients with non-variceal bleeding or in those at higher risk of poor outcomes (GBS≥12, MAP(ASH)≥2, ASA≥3).

Conclusion

Our study highlights, in line with the majority of available ones (5,6), that endoscopy before 12h does not provide a benefit in patients with VB. This necessitates a reconsideration of the ESGE recommendation. Patients with endoscopy performed before 6 or after 24h have poor outcomes. However, multivariate analysis shows that the timing of endoscopy is not an independent prognostic factor for mortality. On the other hand, the decompensation of basal chronic disease and the severity of bleeding (determined by MAP(ASH) and rebleeding) are the determinants of patient outcomes.

References

1. Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy. 2021 Mar;53(3):300-332.
2. Laursen SB, Leontiadis GI, Stanley AJ, Møller MH, Hansen JM, Schaffalitzky de Muckadell OB. Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study. Gastrointest Endosc. 2017 May;85(5):936-944.e3.
3. Gralnek IM, Camus Duboc M, Garcia-Pagan JC, Fuccio L, Karstensen JG, Hucl T, et al.. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022 Nov;54(11):1094-1120.
4. Bai Z, Wang R, Cheng G, Ma D, Ibrahim M, Chawla S, Qi X. Outcomes of early versus delayed endoscopy in cirrhotic patients with acute variceal bleeding: a systematic review with meta-analysis. Eur J Gastroenterol Hepatol. 2021 Dec 1;33(1S Suppl 1):e868-e876.
5. Zhang W, Huang Y, Xiang H, Zhang L, Yuan L, Wang X, et al. Timing of endoscopy for acute variceal bleeding in patients with cirrhosis (CHESS1905): A nationwide cohort study. Hepatol Commun. 2023 May 4;7(5):e0152.

Introduction

Solid-pseudopapillary neoplasm (SPN) is a rare tumor of low malignancy that occurs predominantly in young females. Imaging of SPN is often described as a well-defined and heterogeneous tumor with calcifications or cysts, otherwise small size SPN often shows a homogeneously solid tumor. However, the differential diagnosis between SPN and other cystic tumors is often difficult due to the variety of imaging findings. In this report, we describe the clinical features and preoperative diagnosis of SPN we experienced at our hospital.

Aims & Methods

We studied 18 cases of SPN that were pathologically diagnosed by surgical resection at our hospital between 1997 and 2022.

Results

There were 12 female and 6 male patients, with a median age of 39.5 years (range: 9-67) and a median tumor size of 23 mm (range: 9-66). The tumor location was in the pancreatic head in 4 cases, body in 6 cases, and tail in 8 cases. The median follow-up period was 89.5 months (range: 8-265), and recurrence-free survival was achieved in all cases during the follow-up period. The tumors were incidentally detected in 15 cases during health check-ups (mainly by ultrasonography) or other medical examinations, while the other 3 cases were detected due to subjective symptoms that were thought to be caused by SPN. SPN could be diagnosed by contrast-enhanced CT in 10 of 18 cases (56%) and by EUS in 7 of 12 cases (58%). Contrast-enhanced CT showed enhancing mass in 10 cases, cystic component in 9 cases (50%), and calcification in 8 cases (44%). Among the 8 cases in which SPN could not be diagnosed by contrast-enhanced CT, EUS was performed in 7 cases, and we could diagnose SPN in 2 cases. Both cases had small lesions of less than 13 mm without cystic components, which made the differentiation from other tumors difficult on contrast-enhanced CT, however EUS showed well-circumscribed, well-defined, and homogeneously hypoechogenic tumors. MRI was performed in 12 cases, and could diagnose SPN in 5 cases, but MRI did not improve the diagnostic accuracy compared to contrast-enhanced CT. The diagnostic accuracy of EUS-guided fine needle aspiration (EUS-FNA) was 89% (8/9 cases). There were 5 cases in which SPN could not be diagnosed preoperatively. Among them, 3 cases had small tumor sizes (12-16 mm), and 4 cases lacked calcification, making it difficult to differentiate them from neuroendocrine tumors or solid-cystic neoplasms.

Conclusion

Most cases of SPN are detected incidentally, and regular abdominal ultrasonography during medical check-ups is important for early detection. Diagnosis can be more difficult in cases with small tumor diameter, and no cystic component or calcification. However adding EUS to contrast-enhanced CT imaging may improve accuracy. Furthermore, EUS-FNA contributes to preoperative diagnosis with a high diagnostic accuracy.