Introduction

Surgical criteria for pancreatic cyst lesions are determined by the nodule in the cyst and dilation of the main pancreatic duct, but other imaging factors are needed to improve accuracy.

Aims & Methods

Aims: The present study aimed to identify factors of malignancy resection in intraductal papillary mucinous neoplasms (IPMN) treated at our center by evaluating the malignant portions of resected specimens pathologically to extract new imaging features that may serve as novel indices of malignancy.
Methods: Forty-eight patients with IPMN (14 pancreatic head, 31 body to tail, three total pancreatectomies) with a median age of 71 years (range: 38-84) and a male: female ratio of 35: 13 were enrolled. IPMN was divisible into the main pancreatic duct (n=11), branched duct (n=23), and mixed (n=14) types. Furthermore, 27, ten, and 11 cases of IPMA, high-grade IPMN (HG), and IPMC invasive group (C), respectively, were analyzed. [1] Clinical images of the benign group (A) were compared with those of the malignant group (HG+C) ［2]the malignant specimens and areas of invasion were pathologically analyzed (HG+C). ［3] The malignancy detection rate on DW-MRI was then examined; a higher intensity in the lesion than in the surrounding pancreatic parenchyma indicated positivity.

Results

[1] Age (median: 69 years vs. 73 years; P=0.06), history of pancreatitis (15% vs. 10%; P=0.68), and the preoperative serum mean AMY, CA19-9, and CEA positivity rates did not differ significantly between the benign and malignant groups. HbA1c (mean,%) was higher in the malignant group at 5.9 vs. 6.7 (P=0.03). In terms of imaging features, the proportion of main pancreatic ducts with a diameter >10 mm was 22% and 48% in the respective group (P=0.06); the mean cyst diameter was 33 mm vs. 28 mm (P=0.19); the proportion of contrast-enhanced nodules > 5 mm was 7.4% vs. 52.4% (P<0.01); the positivity rate on DW-MRI was 12% vs. 68% (P<0.01), the detection rate of pancreatic duct stenosis rate on MRI was 11% vs. 38% (P＜0.05); worrisome features (WSF) were found in 42% (20/48) of cases; and high-risk stigmata (HRS) were found in 52% (25/48) of cases. The malignancy rate in the WSF and HRS cases was 20% (4/20) and 68% (17/25), respectively.
[ 2] The histological subtypes of the malignant group were gastric (n=5), intestinal (n=8), oncocytic (n=6), and biliary pancreatic (n=2). Areas of high-grade dysplasia and invasion in the HG group and C group, respectively, were consistent with the presence of a nodule and area of pancreatic duct stenosis.
[ 3] When instances of malignancy were treated as positive, the sensitivity, specificity, positive predictive value, negative predictive value, and positive diagnostic value of HRS was 81%, 70%, 68%, 83%, and 75%, respectively, in the 44 cases while the diagnostic performance of DW-MRI was 68%, 88%, 81%, 79%, and 80% for the respective items. The positivity rate for groups A, HG, and C was 12%, 60%, and 78%, respectively.

Conclusion

The present study of resected IPMN found that DW-MRI provided surgical criteria with a diagnostic performance comparable to the HRS criteria.

Introduction

Hepatitis C virus (HCV) infection is one of the leading causes of liver cirrhosis and hepatocellular carcinoma. Myeloid-derived suppressor cells (MDSC) are a heterogeneous population of activated immature myeloid cells that are characterized by different specific surface molecules, they express each of CD11b+CD33+ and lack expression of HLA-DR. MDSC are immunosuppressive cells that decrease immune cell activation and induce immunological tolerance in inflammation and cancer. Under normal conditions, MDSC remain in the bone marrow until differentiation; however, under pathological conditions these cells arrest at various stages of development, migrate out of the bone marrow in an immature state and, accumulate in circulation and peripheral lymphoid organs, causing negative regulation of immune responses via various mechanisms, primarily T cell suppression. MDSC are known to increase in patients with chronic hepatitis C virus infection. But it is not clear till now if eradication of HCV using directly acting antivirals can restore normal levels of MDSC on long term or not.

Aims & Methods

This study aimed to assess the levels of MDSC in patients with previous chronic hepatitis C after achieving sustained virologic response (SVR) for at least 2 years using sofosbuvir containing regimens.
This study was a case-control one. Fifty five subjects were involved in the study. All patients had completed DAAs therapy 2-3 years before involvement. Estimation of (CD33+ HLA-DR– CD11b+) expressing cells by flow cytometry was done and levels were compared between HCV patients achieved SVR for 2-3 years and healthy control without any current or previous chronic disease.

Results

MDSC were significantly higher among patients with eradicated HCV for 2-3 years than in healthy controls (4.98% (IQR=3.3 – 7.7) vs 3.09% (1.4 – 3.9), p = 0.001)

Conclusion

Normal MDSC levels are not restored after eradication of HCV using directly acting antivirals even after passage of 2 years on viral eradication. Clinical implications and consequences of these findings should be further investigated.

Clinical Case Summary

An hemoperitoneum may be the initial presentation of a liver tumour. A good differential diagnosis is critical, including trauma, vascular rupture and tumours.
A 79-year-old male, retired welder and painter, consulted for weight loss, abdominal pain and distension of 3 months of evolution. Ascitic semiology led to do a paracentesis with hematic debit. An urgent computerized tomography (CT) reported hemoperitoneum secondary to multicentric liver tumor with active bleeding (Figure 1) and intratumoral pseudoaneurysms compatible with angiosarcoma, performing an urgent transarterial embolization (Figure 2). Extension CT ruled out distant disease, magnetic resonance imaging (MRI) was realized (Figure 3) and fine needle aspiration (FNA) showed atypical cellular with CD31 expression (Figure 4), consistent with primary hepatic angiosarcoma (PHA). Given the bilobar involvement, surgery was dismissed and he was treated with chemotherapy (CTX), dying at 10 months of diagnosis.
PHA is a rare entity (2% of primary liver tumor) with an annual prevalence of 200 worldwide cases and a male predominance (3:1) at 60 years. It has been associated to exposure to vinyl chloride, arsenic or thoracotrast, but currently 75% of diagnoses have unknown aetiology.
Diagnosis is based on anatomopathology and inmunohistochemistry, including atypical cellularity in FNA and expression of vascular markers as ERG (100%), CD34 (87%) and CD31 (79%). Imaging tests are non-specific, with hypodense lesions in CT and T2-weighted hyperintense sequence in MRI.
Due to its aggressiveness, around 60% of PHA presents lymph nodes or lung, bones or spleen metastases at diagnosis. Liver resection is the only potentially curative treatment because it is a radioresistent tumour. Transplantation is not recommended due to its high recurrence rate. PHA has less than 6 months of overall survival (OS) without treatment. Otherwise, patients with CTX treatment has a OS of 3% at 2 years of diagnosis.

Introduction

The benefit of computer-assisted detection systems (CADe) has been evaluated in several randomized controlled trials (RCTs) showing improved adenoma detection rate (ADR) and polyp detection rates (PDR) (1-3). However, the generalizability of these studies is questioned as these studies are performed in highly controlled setting and thus not representing a real-world clinical setting (4). It is also believed that the increase in ADR by CADe-assisted colonoscopy is mainly observed in lower detector endoscopists (5, 6).
We aimed to evaluate the effect of CADe-assisted colonoscopy on ADR in an actual clinical setting in a high-volume, non-tertiary endoscopy centre with high detector endoscopists.

Aims & Methods

A single-centre, observational study was conducted on all patients undergoing colonoscopy due to symptoms of colorectal cancer (CRC), screening colonoscopies for CRC, post-polypectomy surveillance, or colonoscopy due to positive results from a fecal immunochemical test in an Australian hospital between March 2023 to October 2023. Colonoscopies were performed by 19 experienced endoscopists using the validated CADe system that allows for real-time image analysis (GI Genius, Cosmo IMD Ireland). Historical procedural data regarding colonoscopies were obtained up to 10 months before the start of the study and were compared to the CADe-assisted colonoscopies in a 2:1 fashion. The primary outcome of the study was the ADR. Data were analyzed using logistic mixed effects models with random intercepts for patient and endoscopist, expressed as Odds ratio (OR) with a 95% confidence interval (CI).

Results

A total of 7798 colonoscopies were performed for 7460 patients during the timeframe, including 2813 colonoscopies using CADe and 4985 standard colonoscopies. The ADR in the CADe-assisted colonoscopy group was 52% compared to 46% in the standard colonoscopy group. There was a significant difference in ADR (OR 1.22, 95% CI 1.09 - 1.36, p<0.001) and PDR (OR 1.22, 95% CI 1.09 - 1.37, p<0.001) between CADe-assisted colonoscopy and standard colonoscopy respectively, adjusted for age, bowel preparation quality, withdrawal time and sex.

Table 1 Adenoma detection and polyp detection rate of the CADe-assisted colonoscopy group compared to the standard colonoscopy group.

Conclusion

In this real-time, observational study, CADe-assisted colonoscopy significantly improves the adenoma detection rate and polyp detection rate. Our study shows that the implementation of CADe-assisted colonoscopies in daily practice is useful, even in high-detector endoscopists.

References

1. Wang P, Liu X, Berzin TM, Glissen Brown JR, Liu P, et al. Effect of a deep-learning computer-aided detection system on adenoma detection during colonoscopy (CADe-DB trial): a double-blind randomised study. Lancet Gastroenterol Hepatol. 2020;5(4):343-51.
2. Repici A, Spadaccini M, Antonelli G, Correale L, Maselli R, et al. Artificial intelligence and colonoscopy experience: lessons from two randomised trials. Gut. 2022;71(4):757-65.
3. Hassan C, Spadaccini M, Mori Y, Foroutan F, Facciorusso A, et al. Real-Time Computer-Aided Detection of Colorectal Neoplasia During Colonoscopy : A Systematic Review and Meta-analysis. Ann Intern Med. 2023;176(9):1209-20.
4. Patel HK, Mori Y, Hassan C, Rizkala T, Radadiya DK, et al. Lack of Effectiveness of Computer Aided Detection for Colorectal Neoplasia: A Systematic Review and Meta-Analysis of Nonrandomized Studies. Clin Gastroenterol Hepatol. 2023.
5. Karsenti D, Tharsis G, Perrot B, Cattan P, Percie du Sert A, Venezia F, et al. Effect of real-time computer-aided detection of colorectal adenoma in routine colonoscopy (COLO-GENIUS): a single-centre randomised controlled trial. Lancet Gastroenterol Hepatol. 2023;8(8):726-34.
6. Mangas-Sanjuan C, de-Castro L, Cubiella J, Diez-Redondo P, Suarez A, Pellise M, et al. Role of Artificial Intelligence in Colonoscopy Detection of Advanced Neoplasias : A Randomized Trial. Ann Intern Med. 2023;176(9):1145-52.

Introduction

Anastomotic leakage after foregut surgeries are often difficult to manage. The conventional way of endoscopic treatment is endoscopic stenting (ES). However, it carries a risk of stent migration and erosion. Endoscopic vacuum therapy (EVT) has recently been proposed as an alternative way of treating these leaks. EVT has the benefit of providing negative suction and promotion of granulation tissue¹. However, an exchange every 3-7 days has been suggested.

Aims & Methods

The aim of this study was to compare the treatment outcomes between ES, EVT and the combination of both. This was a retrospective multi-centre cohort study from 3 major centres in Hong Kong that performs esophagectomy and gastrectomy. All patients with anastomotic leak after total gastrectomy and esophagectomy and who were treated with ES or EVT between Jul 2008 and Apr 2023 from the Prince of Wales Hospital, Queen Mary Hospital and United Chistian Hospital were included. Patients’ demographics, type of surgery, size of anastomotic defect, treatment success rate, complications, number of procedures, duration to healing were recorded and compared. Continuous data are compared with Mann-Whitney test and categorical data are compared with Chi-square/ Fisher's exact test.

Results

A total of 63 patients were recruited (ES: 49; EVT 14. The outcomes of the study are listed in Table 1. The mean (S.D.) of defect was 15.4 (16.0)mm in the ES group and 17.8 (14.1)mm in the EVT group (p=0.39). in the EVT group, there are 3/14 patients who had failed EVT therapy and converted to ES. The success rate of each arm as a single arm therapy were similar (29/49(59.2%) in the ES group vs 6/14(42.9%) in the EVT group; p=0.28). However, there were less complications in the EVT group (2/14 (14.3%) in ES group vs. 23/49(46.9%) in EVT group; p=0.03). On the other hand, the EVT group required more endoscopic procedures (median (range) 3 1-137) procedures in the ES group vs 6(2-16) in the EVT group ; p 0.002). The days required for the anastomosis to heal were also similar (ES (61.7 (38.4) vs EVT 45.3 (25.8); p=0.37). When comparing patients treated as a single-arm therapy (ES or ET) to combination therapy (ES + EVT), the success rates has a trend towards favouring combination treatment (p=0.07).

Conclusion

Both EVT and ES are feasible and safe in treating anastomotic leaks after foregut surgeries. Although more procedures are required, EVT achieved similar success rate while having less complications when compared to ES a single arm. The use of combination therapy as compared to single-arm endoscopic therapy may achieve a higher treatment success rate.

References

1. Chan SM, Auyeung KKY, Lam SF, Chiu PWY, Teoh AYB. Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas. Dig Endosc. 2022 Jan;34(1):43-62. doi: 10.1111/den.14061. Epub 2021 Jul 19. PMID: 34115407.

Disclosure

There is no COI.

Clinical Case Summary

A 43-year-old woman with a rectal 90mm granular laterally spreading tumor involving 50% of the circumference (distal limit at 12cm from the anal verge) underwent endoscopic submucosal dissection (ESD). Due to submucosal fibrosis, deep laceration of the muscularis propria occurred at the end of the procedure and two through-the-scope (TTS) clips were applied and broad-spectrum antibiotics were administered. In the following day, the patient developed sepsis and an emergency CT scan revealed free air in mesorectum and densification of the perirectal/presacral adipose tissues with contrast extravasation. Proctosigmoidoscopy showed an orifice of approximately 12mm, near the previous TTS clips, that communicated with a 15mm abscessed cavity, compatible with delayed perforation (Figure 1). Endoluminal vacuum therapy (EVT) was initiated with a 2cm Endo-SPONGE^® (B.Braun Medical B.V., Melsungen, Germany), partially intraluminal, without immediate complications (Figure 2). The patient was kept under parenteral nutritional, antibiotics and twice weekly EVT sponge replacement, with a total of four substitutions. The evolution was favorable with sepsis resolution, decrease of the cavity length and complete tissue granulation (Figure 3). The patient was discharged after 16 days and remained asymptomatic with complete closure at the 1.5 months follow up (Figure 4).

References

(Figure 1). (Figure 2). (Figure 3) (Figure 4).

Introduction

Low-code/no-code (LCNC) applications are under-utilised as clinician-built solutions for daily hospital-based tasks. Waikato Hospitals endoscopy unit in Hamilton, New Zealand, on average receives five to twelve acute endoscopy requests per day. Prior to December 2021 all inpatient endoscopy requests for conditions such as gastrointestinal bleeding, were made on handwritten paper and faxed to the endoscopy unit. Following this the co-ordination and triage of multiple referrals occurred onsite from a single physical board. This created problems such as forms being lost, handwriting illegible and co-ordination and communication inefficient. Environmental sustainability was also a major concern regarding paper wastage.

Aims & Methods

We aimed to develop a referral and management system for acute endoscopy requests using LCNC technology. This would be built and maintained by the endoscopy staff and tailored to clinical and administrative needs. We used the Microsoft Power Platform, Power Automate and Power Apps, to develop this clinician-built triage and management system, alongside an electronic referral request for acute endoscopy from Clinical Work Station™ (Waikato Hospitals electronic medical records system). The system was developed by a Gastroenterology Trainee with experience in LCNC systems, and was developed with the endoscopy staff. The electronic referral system went live on 6th of December 2021.

Results

From December 2021 to August 2022, our clinician-built system had 4512 visits with up to 44 unique users monthly using the Microsoft PowerApp through mobile and desktop, either directly or through Microsoft Teams. The Microsoft Power App recorded 1201 new endoscopy referrals, of which 1007 (84%) endoscopies were completed, 56 (5%) duplicate referrals, 17 (1%) triaged to outpatient endoscopy and 111 (10%) declined or cancelled back to the referrer. 1177 (98%) referrals utilised the electronic notifications setting between clinicians, nursing and administration staff using push notifications, minimising the need for face-to-face contact and physically meeting. The system eliminated paper waste, while also optimised patient care by real time co-ordination of referrals and improved documentation when making or changing triage decisions. Prior to December 2021 there were 15 steps from the patient presenting to hospital with a gastrointestinal bleed to having their endoscopy completed, now the process is shortened to seven steps, with instant upload of requests upon submission of an endoscopy request and real-time tracking. 10 endoscopy staff including 2 doctors and 6 endoscopy nurse co-ordinators provided positive feedback and support for its ongoing use during staff surveys.

Conclusion

The LCNC system we have developed is clinician focused, modified for our needs and is built on current Microsoft 365™ licencing, which does not incur extra costs to our hospital, and allows integration into Microsoft Outlook™ and Microsoft Teams™. In the short time our system has been online, it has demonstrated efficiency, sustainability, and safety for patient care with high levels of clinician satisfaction and has potential to be integrated to other hospitals with similar Microsoft 365™ licencing.