Introduction

A common finding in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) is periampullary diverticulum (PAD). It is more prevalent in females and elderly patients but is also linked to cholangitis and common bile duct stones. The anatomy may be distorted by PAD, possibly making papilla cannulation challenging. Whether PAD increases the difficulty of cannulation and whether it is linked to a higher incidence of adverse events has been debated. To provide further insights into this scenario, we conducted a nationwide registry-based study.

Aims & Methods

Our objective was to determine the impact of PAD on the cannulation rate, adverse events, and ERCP duration. We collected data on ERCP procedures performed between 2006 and 2021 from the Swedish Registry for Gallstone Surgery and ERCP (GallRiks). The 125,558 ERCPs that were registered in the registry during the study period were reduced to 73,937 after we excluded rendezvous procedures, previous sphincterotomies, previous stenting, and procedures with missing follow-up data.

Results

PAD was discovered in 12,782 (10.2%) ERCPs, with data recorded in the registry, and was present in 8,589 (11.6%) ERCPs in the study population. For 2,796 (3.8%) of the patients in the study group had the papilla inside the PAD (Boix Type 1), while 5,793 (7.8%) of the patients had a papilla on the edge of the PAD (Boix Type 2) or immediately next to it (Boix Type 3). The probability of successful cannulation was greater in non-PAD patients (89.7% vs. 88.6%; P=.002), whereas successful cannulation was reduced to only 81.1% if the papilla was located within the PAD (Type 1) (P<.001). The procedure time did not differ between the PAD (37.4 min) and non-PAD (37.5 min) groups (P=.73). There were no differences in intraprocedural complications (3.1%) or adverse events (16.4% vs. 15.5%; P=.05), whether PAD was present or not. In the PAD group, the risk of bleeding increased (1.8% vs. 1.3; P=.001). The perforation risk did not differ across the groups (PAD 0.8% vs. 0.7% non-PAD; P=.22), however PAD had a reduced incidence of cholangitis (1.8% vs. 2.3%; P=.01) and pancreatitis (4.5% vs. 5.2%; P=.008).

Conclusion

The cannulation rate is slightly reduced in the presence of PAD, and this effect is more pronounced and particularly apparent in patients with Type 1 PAD. The safety of ERCP is unaffected by the presence of PAD.

References

[1] Boix J, Lorenzo-Zúñiga V, Añaños F, et al. Impact of periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula. Surg Laparosc Endosc Percutan Tech 2006; 16: 208–211.
[2] Tham TCK, Kelly M. Association of periampullary duodenal diverticula with bile duct stones and with technical success of endoscopic retrograde cholangiopancreatography. Endoscopy 2004; 36: 1050–1053.
[3] Loffeld RJLF, Dekkers PEP. The Impact of Duodenal Diverticuli and the Execution of Endoscopic Retrograde Cholangiopancreaticography. Int Sch Res Not 2016; 2016: 5026289.
[4] Sun Z, Bo W, Jiang P, et al. Different Types of Periampullary Duodenal Diverticula Are Associated with Occurrence and Recurrence of Bile Duct Stones: A Case-Control Study from a Chinese Center. Gastroenterol Res Pract 2016; 2016: 9381759.
[5] Corral JE, Mousa OY, Kröner PT, et al. Impact of Periampullary Diverticulum on ERCP Performance: A Matched Case-Control Study. Clin Endosc 2019; 52: 65–71.
[6] Tabak F, Ji G-Z, Miao L. Impact of periampullary diverticulum on biliary cannulation and ERCP outcomes: a single-center experience. Surg Endosc 2021; 35: 5953–5961.

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

The Maastricht V/ Florence Consensus has updated guidelines for the management of Helicobacter Pylori (HP) infection with special emphasis in high clarithromycin resistance settings as it is the case in our country. In line with the recommendations of the European Guidelines on surgery of severe obesity [1] and the recommendations of the American Society of Gastrointestinal Endoscopy on endoscopy of the bariatric patient [2) a policy of systematic HP screening and overtime updated eradication was implemented in obese patients undergoing Roux-en Y gastric bypass (RYGB) surgery.

Aims & Methods

Five year period (2020-2024) single center study. The aim was, in obese patients undergoing RYGB surgery, to assess the cumulative HP eradication rate by adopting, at first line, a 10 days bismuth quadruple therapy (BQT) - proton pump inhibitor (PPI) bid and three-in-one single capsule containing bismuth, metronidazole, and tetracycline qid - and, at second line, a 14 days levofloxacin based therapy ( LBT) – PPI bid, amoxicillin 1000 mg bid and levofloxacin 500mg bid. HP infection status was assessed, at baseline, by histology or urea breath test and post treatment, by urea breath test 4-6 weeks after the end of the therapy.

Results

One thousand four hundred and forty-nine consecutive HP‑positive patients completed BQT treatment: 1160 (80.1%) female, age 43.5 (±10.5) years, median age of 44 years), age range of 18-69 years. HP was eradicated in 1220 patients – 84.2% (95%CI: 82.2%-86.0%). In the remaining 229 patients, 87 patients withdrew and HP was eradicated in 118 patients out of 145 with LBT. The intention to treat (ITT) and per protocol (PP) cumulative eradication rates were, respectively, 92.3% (95%CI: 90.9%-93.6%). and 98.0% (95%CI: 97.1%-98.6%). Eradication rates were not significantly different by gender and age.

Conclusion

By adopting the Maastricht V/ Florence Consensus BQT first line therapy and second line LBT therapy, high ITT and PP cumulative HP eradication rates are achieved leaving only a residual number of obese patients undergoing RYGB in need of the culture and susceptibility testing prior to third line treatment.

References

1. Fried M, Hainer V, Basdevant A, et al. European Guidelines on surgery of severe obesity. . International Journal Of Obesity 2007;31:569-577.
2. ASGE Guidelines. Role of endoscopy in the bariatric patient. Gastrointest Endosc 2008; 68:1-10.

Disclosure

NO CONFLICT OF INTEREST

Introduction

Granulocyte–monocyte apheresis (GMA) is a non-pharmacological therapy approved for the treatment of ulcerative colitis (UC), mainly in steroid-dependent cases. Its mechanism of action is based on the removal of activated leukocytes, but its exact immunological changes have not been fully described yet.

Aims & Methods

Our aim was to characterize the response in the transcriptome at the single-cell resolution level and cell population effects of GMA device. We analysed scRNASeq data from peripheral blood mononuclear cells (PBMC) of two UC patients undergoing their first GMA session. Their gene expression profile was compared before (PRE) and one month after (POST) the GMA treatment, from the inflow and outflow lines, respectively. The analytical pipeline included quality control and filtering, cell-type annotation, differential gene expression and pathway enrichment analysis.

Results

Two patients with UC (mean age 59 years; both E2) were included. Overall, the cell populations that appear to have been affected by the GMA treatment were natural killer cells and monocytes with both populations being reduced after the treatment. The distribution of the annotated cell-types was 2,369 B cells (PRE:50%, POST:49%), 11,462 CD4+ (PRE:49%, POST:50%) and 8,845 CD8+ T-cells (PRE:51%, POST:48%), 47 dendritic cells (PRE:40%, POST:59%), 3,773 natural killer cells (PRE:54%, POST:45%) and 2,352 monocytes (PRE:59%, POST:40%). Annotation at higher resolution identified 27 cell-types with monocytes being subannotated as 1,972 CD14 (PRE:62%, POST:37%) and 380 CD16 (PRE:48%, POST:51%) monocytes. Differential gene expression analysis identified in total 86 significant genes across six cell-types (CD4+ naive and central memory T-cells, natural killer cells, B intermediate cells, double-negative T-cells and CD14 monocytes) with 63% of these genes being downregulated after the GMA treatment. Pathway enrichment analysis identified higher contribution of the double-negative T-cells to the enriching genes. More specifically, after the treatment the double-negative T-cells exhibited upregulation of the NEFL that is associated with the MAPK cascade and downregulation of genes related to immune response and signalling pathways. Regarding the CD14 monocytes, after the GMA treatment we observed significant downregulation of the genes LINC02315, IGHEP1 and IGHE, with the latter being linked to innate immune response pathways.

Conclusion

GMA induces a range of modifications in the gene expression profile across different cell types that change the immunological environment of UC patients.

Disclosure

Financial support from an unrestricted grant from Adacyte, who had no role in the study design, interpretation of data or drafting the abstract.

Clinical Case Summary

Introduction: Locally advanced pancreatic tumors can lead to both biliary and duodenal obstruction by invasion or compression. Quality of life is severely affected if obstruction occurs: jaundice, emesis and pain can become invalidating and patients become too frail for palliative chemotherapy and are sometimes declared unfit even for derivative surgery. Recently, endoscopic techniques under EUS or ERCP guidance are being used to create biliodigestive and enteral anastomoses.
Clinical case: A 75-year-old female was diagnosed with locally advanced pancreatic head adenocarcinoma in January 2024. The tumor was declared unresectable and chemotherapy was initiated. A plastic stent was inserted into the main biliary duct (MBD) to ensure biliary drainage. In May 2024, she presented with cholangitis and emesis. EGD revealed duodenal stenosis and ERCP failed due to tumor infiltration. A combined endoscopic approach was performed: EUS-guided hepatico-gastrostomy (EHG) for biliary drainage and EUS-guided gastro-enterostomy using a lumen-apposing metal stent (LAMS). In July 2024, the plastic stent was removed, and in August 2024, two fully covered 60 x 10 mm SEMS were inserted antegrade through the EHG into the MBD to improve patency. At 11 months post-intervention, the patient returned for routine reassessment, declaring good clinical performance: she remained asymptomatic, with routine blood tests, including bilirubin levels within normal range and with all stents patent and correctly positioned (confirmed radiologically and endoscopically). The patient was able to maintain oral intake and continue chemotherapy. No late adverse events were noted.
Conclusion: This case demonstrates the long-term clinical and technical success of a staged endoscopic triple bypass for the management of complex biliary and duodenal obstruction due to unresectable pancreatic cancer. The approach was minimally invasive, well tolerated and remarkably improved the patient's quality of life.

References

1. Adler, Douglas G MD; Baron, Todd H MD, FACP. Endoscopic Palliation of Malignant Gastric Outlet Obstruction Using Self-Expanding Metal Stents: Experience in 36 Patients. American Journal of Gastroenterology 97(1):p 72-78, January 2002. | DOI: 10.1111/j.1572-0241.2002.05423.x
2. Giovannini, Marc. (2019). EUS-guided hepaticogastrostomy. Endoscopic Ultrasound. 8. 35. 10.4103/eus.eus_47_19.
3. Dumonceau, Jean-Marc & Tringali, Andrea & Blero, Daniel & Devière, J & Laugiers, R & Heresbach, D & Costamagna, Guido. (2012). Biliary stenting: Indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy. 44. 277-98. 10.1055/s-0031-1291633.
4. Van Der Merwe, S. W., Van Wanrooij, R. L., Bronswijk, M., Everett, S., Lakhtakia, S., Rimbas, M., ... & Van Hooft, J. E. (2022). Therapeutic endoscopic ultrasound: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy, 54(02), 185-205. 10.1055/a-1717-1391

Introduction

Xanthine oxidase (XO) catalyzes the oxidation of hypoxanthine to xanthine and xanthine to uric acid (UA) with the production of superoxide anion. The accumulation of UA has been shown to initiate the inflammatory process through NLRP3 inflammasome and the production of reactive oxygen species (ROS), which contributes to inflammation-related tissue damage observed in inflammatory bowel disease (IBD). In murine models of colitis, XO inhibitors, allopurinol or febuxostat, reduced the expression of proinflammatory cytokines supporting the involvement of XO in the intestinal inflammatory process.

Aims & Methods

The aim of this study was to evaluate the expression level and enzymatic activity of XO in the intestinal mucosa of IBD patients (pts), both ulcerative colitis (UC) and Crohn’s disease (CD), compared to healthy controls (HC).
Sigmoid-colon biopsies from consecutive UC and CD pts, with a confirmed diagnosis (by ECCO guidelines) in regular follow-up at University Hospital of Cagliari with an indication to endoscopy according to standard clinical practice, were collected. Site-matched biopsies from individuals undergoing screening colonoscopy for colorectal cancer were used as controls.
Demographic data and endoscopic grade for disease activity scored by endoscopic Mayo and SES-CD score were collected. Real-Time PCR was used to evaluate XO relative expression levels (RQ) and data was confirmed by analyzing GEO database (study code GSE11223). XO activity was measured in whole protein extracts from biopsies by spectrophotometric quantification of UA production and expressed as nmol of UA/min/mg of total protein. The relative abundance of XO was further investigated by Western Blot. Finally, XO expression was assessed in sections of paraffin-embedded intestinal biopsies by immunohistochemistry.

Results

Biopsies of 15 HC, 20 UC, and 15 CD pts were collected. Mean age was 50 for UC, 49 for CD and 54 for HC. Mayo endoscopic subscore was 0 in 25% of UC pts, 1 in 18,75%, 2 in 21,2% and 3 in 25%. SES-CD was between 0-2 in 28,6% of CD pts, 3-6 in 21,4%, 7-14 in 42,8% and >14 in 7,1%. Real-time PCR showed that XO expression values were increased in the sigmoid mucosa of pts with UC compared with HC individuals (RQ 1,93 vs 0,99. p=0,004). This data was confirmed by analysis of XO expression in the GEO database study code GSE11223. The difference in XO expression between HC and CD was not statistically significant (p=0,13). Western blot analysis of XO protein expression in CD and UC pts compared with HC showed a significant increase in IBD pts (p<0,001).
XO activity was significantly higher in UC and CD pts as compared to HC. XO activity mean was 3,75 in UC pts and 5,10 in CD pts vs 1,11 nmol of UA/min/mg of protein in HC individuals (p<0.001). Moreover, in UC pts XO activity was correlated with Mayo endoscopic sub-score (r= 0.346; p=0.05). Immunohistochemistry confirmed higher expression of XO in IBD pts than HC with a prevalent expression observed in epithelial cells.

Conclusion

XO expression was higher in UC pts than in HC individuals. XO activity was higher in both CD and UC pts than HC and in UC pts XO activity correlated with endoscopic disease suggesting its potential role as therapeutic target.