Introduction

Pancreatic adenocarcinoma has a poor prognosis with an overall 5-year survival rate of 10% as most patients present with unresectable or metastatic disease. Evaluation of microsatellite instability (MSI) or deficient DNA mismatch repair (dMMR) status can tailor treatment to increase the efficacy of systematic therapy. However, the adequacy of tissue samples obtained by routine endoscopic ultrasound-guided fine needle biopsy (EUSFNB) of pancreatic adenocarcinoma for MSI/dMMR assessment remains unclear. This study evaluated the role of EUSFNB using the Procore (Cook Medical) biopsy needles for MSI/dMMR assessment. In recent years, a new 20G Procore needle has been developed to overcome the limitations of tissue acquisition of the smaller needles (22G,25G) and the rigidity of the larger one (19G). We also aimed to study the performance assessment between Procore 20G vs 22G needles in tissue acquisition for MSI/dMMR assessment.

Aims & Methods

This was a single-centre study reviewed patients with suspected pancreatic adenocarcinoma who underwent diagnostic EUSFNB in a tertiary referral centre using either 20G or 22G Procore needles from January 2022 to March 2023. The newer 20G Procore needle was designed with a forward side-bevel, whereas the 22G needle had a reverse side-bevel, for tissue core acquisition. Clinical data and characteristics of lesions in all patients undergoing EUSFNB in the participating site are prospectively maintained in a registry for quality control and audit purposes. All cases of adenocarcinoma were tested for MSI/dMMR status by immunochemistry (MLH1, MSH2, MSH6 & PMS2). The primary study outcome measure was the adequacy of tissue samples for MSI/dMMR testing. Secondary outcomes were the rate of histological core tissue acquisition, the difference in the adequacy of tissue for MSI/dMMR testing between 20G and 22G Procore needles and the rate of MSI-high pancreatic adenocarcinoma. The impact of the use of these needles in obtaining adequate tissue on patient management was also evaluated.

Results

A total of 31 patients (mean age 68.2 SD± 8.17; 51% male) with pancreatic adenocarcinoma were included in the study. The mean size for the pancreatic mass was 33.17 SD±20.4 with most of the pancreatic mass located at the pancreatic head, uncinate, and neck region 70% (21/31). The histological yield of EUSFNB was 100%. Overall tissue adequacy rate for MSI/dMMR assessment was 80% (25/31), which was higher with 20G compared to 22G Procore needles (88.8%;16/18 vs 69.2%;9/13, p-value = 0.207). Two of the 23 patients with successful MSI/dMMR testing (8.7%) had MSI-high status. One received second-line treatment with pembrolizumab, and the other received the best supportive care due to worsening liver function and poor functional status.

Conclusion

This study affirmed the feasibility of routine MSI testing from specimens acquired by EUSFNB using the Procore EUSFNB needles. Our results also suggested that the larger 20G Procore needle with forward side-bevel had a higher yield for MSI testing than the 22G needle with reverse side-bevel, even though both needle types could obtain tissue cores for histology, and this should be reassessed by a further study with larger sample size that is adequately powered.

Disclosure

None

Clinical Case Summary

Intra-ampullary papillary tubular neoplasms (IAPNs) are rare neoplastic intraepithelial lesions that occur within the ampulla. Given their well-documented malignant potential, early recognition and intervention are paramount to prevent malignant transformation. We present a case of IAPN successfully managed via endoscopic papillectomy.
A 58-year-old male was incidentally found to have a bulky-appearing ampulla of vater during esophagogastroduodenoscopy as part of routine health screening. Endoscopic ultrasonography revealed a 20-mm hyperechoic lesion at the ampulla, with histopathological evaluation demonstrating low-grade dysplasia (indeterminate for neoplasia). Laboratory investigations, including hematological parameters, biochemical profiles, and tumor markers, were within normal limits. Contrast-enhanced abdominal CT demonstrated a well-defined, homogeneously enhancing 20-mm lesion at the ampullary region without biliary/pancreatic duct dilation.
Endoscopic papillectomy was performed using a duodenoscope with snare. Prophylactic stents were placed in both the biliary and pancreatic ducts to ensure adequate drainage. Any intraprocedural bleeding was promptly controlled with hemoclip application. Histopathological analysis confirmed high-grade IAPN, characterized by a polypoid tumor with closely packed tubular glands lined by pseudostratified columnar epithelium showing loss of polarity and moderate nuclear atypia (Ki-67 index: 50%). The postoperative course was uncomplicated, with discharge achieved on the sixth postoperative day. At six-month follow-up evaluation, surveillance endoscopic ultrasonography showed no evidence of recurrence.
IAPN represents a distinct neoplastic ampullary entity within the spectrum of ampullary tumors. While endoscopic resection demonstrates therapeutic efficacy, its implementation requires advanced endoscopic expertise in specialized centers.

References

Endoscopic ultrasonography revealed a 20-mm hyperechoic lesion at the ampulla
Endoscopic papillectomy was performed using a duodenoscope with snare. Prophylactic stents were placed in both the biliary and pancreatic ducts to ensure adequate drainage. Any intraprocedural bleeding was promptly controlled with hemoclip application.
Histopathological analysis confirmed high-grade IAPN, characterized by a polypoid tumor with closely packed tubular glands lined by pseudostratified columnar epithelium showing loss of polarity and moderate nuclear atypia (Ki-67 index: 50%).

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

Clinical Case Summary

The endoscopic removal of polyps located at the appendiceal orifice is a challenge, particularly when extending inside the appendiceal lumen, due to its anatomic difficulty and risk of complications.
The endoscopic full-thickness resection (FTR) technique has become an non-surgical option for these lesions but with a non negligible risk of appendicitis.
With the present case we explore an alternative technique.
A 75-year-old man with iron deficiency anemia underwent upper digestive endoscopy and colonoscopy.
The upper digestive endoscopy was normal.
In the colonoscopy angiectasias were found in the cecum and multiple polyps in the left colon (the largest measuring 30 mm). The inspection of the appendix revealed an intra-appendiceal orifice lesion (Image A).
Only after inversion of the appendix it was possible to accurately assess the lesion: an approximately 15 mm sessile polyp (Images B, C).
We applied argon plasma for ectasias ablation and removed the left colon polyps by endoscopic mucosal resection.
Intra-appendiceal orifice polyp resection was performed underwater with a diathermic loop (Image D), with no immediate or late complications.
Histology revealed a sessile serrated adenoma with low-grade dysplasia.
The described technique, being a simpler, faster and cheaper option than the endoscopic-FTR is a valid and a cost effective one.

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

Adequacy of bowel preparation (ABP) directly affects colonoscopy performance and adenoma detection rate. Studies attributed a role to the dosing regimen of the bowel cleansing agent, social and economic factors and comorbidities. However, data on the impact of kidney failure and renal replacement therapy (RRT) are lacking.

Aims & Methods

This study investigated how ABP compares between patients on RRT and age-matched subjects with normal kidney function.
All patients on RRT undergoing an elective colonoscopy between January 2016 and December 2021 were identified from the medical records of a university hospital, and matched to 2 closest age controls undergoing colonoscopy at the same date ± 7 days. Study subjects and controls were compared for demographics, comorbidities including history of abdominal surgery, use of bowel transit-influencing drugs, residential care stay and colonoscopy-related data (bowel preparation regimen, sedation type, colonoscopy findings, ABP defined as a cumulative Bristol Bowel Preparation Score >= 6 and a score of >= 2 for each colon segment). Statistical significant contributors to ABP were assessed by logistic regression.

Results

Ninety-one patients on RRT (76 on haemodialysis and 15 on peritoneal dialysis) and 182 controls were identified. Patients on RRT were older (69±12 vs. 64±14y, p=.008) and less frequently women (34% vs. 50%, p=.013). They had more diabetes (40% vs. 24%, p=.008), more history of abdominal surgery (32% vs. 21%, p=.047) and took more bowel transit-influencing drugs (50% vs. 28%, p<.0001). Bowel preparation regimens were equally distributed between both groups. There was no difference in the rate of ABP between groups (87% vs. 81%, p=NS). Logistic regression analysis did not reveal an association between RRT and ABP. ABP was negatively influenced by residency in residential care, overnight stay in the hospital before colonoscopy, history of central nervous system disease, and positively by split-dose regimen (Nagelkerke R square 0.329, p=<.001).

Conclusion

Despite less favourable associated conditions, ABP in RRT patients remains comparable to controls. Split-dose regimen, neurological conditions and in-hospital stay are significant predictors of adequate bowel preparation.

References

Clark BT, Rustagi T, Laine L. What level of bowel prep quality requires early repeat colonoscopy: systematic review and meta-analysis of the impact of preparation quality on adenoma detection rate. Am J Gastroenterol. 2014;109(11):1714-23; quiz 24.
Hassan C, East J, Radaelli F, Spada C, Benamouzig R, Bisschops R, et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2019. Endoscopy. 2019;51(8):775-94.
Saumoy M, Jesudian AB, Aden B, Serur D, Sundararajan S, Sivananthan G, et al. High prevalence of colon adenomas in end-stage kidney disease patients on hemodialysis undergoing renal transplant evaluation. Clin Transplant. 2016;30(3):256-62.
24. Calderwood AH, Schroy PC, 3rd, Lieberman DA, Logan JR, Zurfluh M, Jacobson BC. Boston Bowel Preparation Scale scores provide a standardized definition of adequate for describing bowel cleanliness. Gastrointest Endosc. 2014;80(2):269-76.
25. Clark BT, Protiva P, Nagar A, Imaeda A, Ciarleglio MM, Deng Y, et al. Quantification of Adequate Bowel Preparation for Screening or Surveillance Colonoscopy in Men. Gastroenterology. 2016;150(2):396-405; quiz e14-5.
artel M, Barkun AN, Menard C, Restellini S, Kherad O, Vanasse A. Split-Dose Preparations Are Superior to Day-Before Bowel Cleansing Regimens: A Meta-analysis. Gastroenterology. 2015;149(1):79-88

Introduction

Preoperative carbohydrate rich drink (CHO) is a component of the Enhanced Recovery After Surgery (ERAS) protocol and has been shown to improve patient discomfort during fasting. Evidence on its efficacy prior to endoscopic procedures such as oesophagogastroduodenoscopy (OGD) is limited.

Aims & Methods

We aimed to investigate whether CHO given prior to OGD can reduce fasting related discomfort and improve overall patient satisfaction. The primary objective was to evaluate if CHO given pre-OGD reduces fasting related discomfort and improves patient satisfaction compared to the other arms. The secondary objectives were to assess the effects of CHO consumed pre-OGD on procedural risks and gastric preparation quality.
This was a single centre, single-blinded randomised controlled trial. Patients undergoing elective outpatient OGD were randomised into 3 arms: CHO vs Water vs Fasting. All patients were instructed to fast 6 hours pre-OGD. Patients in the CHO and water arms consumed CHO (50g Nestle Preload^TM mixed with 400ml water) and 400ml of water only up to 2 hours pre-OGD. Exclusion criteria were: ASA (American Society of Anaesthesiologists), conditions and medication affecting gastrointestinal motility, pregnancy and diabetes. 30 minutes pre-OGD, patients completed a questionnaire consisting of 11 questions on a 9-point Likert scale pertaining to preprocedure discomfort and symptoms such as vomiting, abdominal pain and fatigue. Post-procedure, endoscopists blinded to the study arm, filled up a questionnaire recording complications and gastric preparation quality. One-way ANOVA test was used to compare the mean scores amongst the 3 groups for each question using SPSS version 27.

Results

262 out of 300 patients recruited were analysed. 52.3% were female and the mean age was 54 years. The predominant indication for OGD was dyspepsia. Our results (Figure 1) showed that patients in the CHO arm were significantly less hungry (4.68 vs 5.95; p=0.004) compared to the fasting arm and experienced less abdominal pain prior to OGD (1.74 vs 2.47; p=0.023). There was however no significant difference between the CHO arm vs water for hunger and pain.. Patients in both CHO (4.69 vs 5.86; p= 0.010) and Water arms (4.68 vs 5.86; p= 0.009) were less thirsty compared to those in the fasting arm. (Table 1). We observed a trend in reduction of depression and feeling weak in the CHO arm as compared to the fasting and Water arm, however these results did not reach statistical significance. There were no overall complications. 10.7% of patients had suboptimal gastric preparation with no significant difference amongst the 3 arms. Logistic regression analysis showed that younger age was associated with suboptimal gastric preparation(p=0.043).

Table 1: Mean Likert Scale Score for each variable. 1=strongly disagree, 3=disagree, 5=neutral, 7=agree, 9=strongly agree

Conclusion

CHO consumption pre-OGD reduces hunger, thirst and abdominal pain compared to fasting. Water consumption pre-OGD yielded similar results, with CHO appearing to suppress hunger better. Importantly, all the patients who consumed clear fluids pre-OGD had no significant residual gastric fluid. We propose that allowing consumption of water or CHO up to 2 hours pre-OGD may reduce discomfort during fasting. Larger studies are required to detect significant differences between CHO and Water and overall cost-effectiveness.

References

Hausel J, et al. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients. Anesth Analg 2001 Nov