Introduction

Pancreatic neuroendocrine tumors (PanNETs) are rare neoplasms characterised by a highly heterogeneous biological behaviour. Currently available preoperative prognostic factors for Non-functioning Pancreatic Neuroendocrine Tumors (NF-PanNETs) still struggle to properly predict tumor aggressiveness, making an adequate management of these lesions hard to be achieved. Aims of this study were: i) to evaluate treatment appropriateness in patients submitted to surgery for NF-PanNETs, and ii) to investigate preoperative features predicting under- or over-treatment in these patients.

Aims & Methods

Patients who underwent curative surgery (R0-R1) for NF-PanNETs at San Raffaele Hospital (Milan, Italy) between November 2002 and March 2022, were retrospectively analysed. Treatment appropriateness was categorized as appropriate treatment, overtreatment, and undertreatment. The presence of features of aggressiveness at final histology and the occurrence of disease relapse within one year from surgery were considered to define treatment appropriateness.

Results

Conclusion

Overtreatment occurs in almost one-third of patients undergoing surgery for NF-PanNETs. However, over the last decade, the percentage of appropriately treated patients has been steadily increasing. A more careful assessment of lesions located in the pancreatic body-tail and/or with a radiological diameter <25.5mm should be performed in order to increase the adequacy of treatment selection.

Introduction

Hepatocellular carcinoma (HCC) is a global problem being fourth in terms of cancer-related deaths¹. Contrast-enhanced ultrasound (CEUS) is used as an add-on test to confirm focal liver lesions suspected as HCC at prior diagnostic tests such as ultrasound or alpha-foetoprotein, or both^2,3. According to guidelines^4,5,6, a single contrast-enhanced imaging techniques, with either computed tomography (CT) or magnetic resonance imaging (MRI) showing the typical hallmarks is sufficient to diagnose HCC in cirrhotic patients. However, a significant number of HCC show atypical imaging features, and therefore, are missed at imaging.
The advantages of CEUS over CT and MRI is the use of contrast agents not containing iodine and that are not nephrotoxic, and quick image acquisition. Despite the advantages, the use of CEUS in the diagnostic algorithm for HCC remains controversial, with disagreement on relevant guidelines.

Aims & Methods

The aim was to assess the diagnostic accuracy of CEUS for the diagnosis of HCC of any size and at any stage in adults with chronic liver disease, in a surveillance programme or in a clinical setting and to assess the diagnostic accuracy of CEUS for the diagnosis of resectable HCC in people with chronic liver disease and identify potential sources of heterogeneity in the results.
We included studies assessing the diagnostic accuracy of CEUS for the diagnosis of HCC in adults with chronic liver disease, with cross-sectional designs, using one of the acceptable reference standards, such as pathology of the explanted liver, and histology of resected or biopsied focal liver lesion with at least a six-month follow-up.
Standard Cochrane methods ⁷ were used to screen studies, extract data, and assess the risk of bias and applicability concerns, using the QUADAS-2 checklist⁸. We used the bivariate model and provided estimates of summary sensitivity and specificity. We assessed the certainty of the evidence using GRADE^9,10. We presented uncertainty-of-the-accuracy estimates using 95% confidence intervals (CIs).

Results

We included 23 studies with 6546 participants. Studies were published between 2001 and 2021. We judged all 23 studies at high-risk of bias in at least one domain, and 13/23 studies at high concern for applicability. Most studies used different reference standards to exclude the presence of the target condition. The time interval between the index test and the reference standard was rarely defined. We also had major concerns on their applicability due to the participant characteristics.
CEUS for HCC of any size and stage: sensitivity 77.8% (95% CI 69.4% to 84.4%) and specificity 93.8% (95% CI 89.1% to 96.6%) (23 studies, 6546 participants; very low-certainty evidence).
CEUS for resectable HCC: sensitivity 77.5% (95% CI 62.9% to 87.6%) and specificity 92.7% (95% CI 86.8% to 96.1%) (13 studies, 1257 participants; low-certainty evidence).
The observed heterogeneity in the results remains unexplained.

Conclusion

Using CEUS, as an add-on test following abdominal ultrasound, to diagnose HCC of any size and stage, 22% of people with the tumor would be missed, and 6% of people without would unnecessarily undergo further testing or inappropriate treatment. As to resectable HCC, we found that 23% of people with resectable tumor would incorrectly be unresected, while 8% of people without HCC would undergo further inappropriate testing or treatment. The uncertainty resulting from the high risk of bias of the included studies, heterogeneity, and imprecision of the results and concerns on their applicability limit our ability to draw confident conclusions.

References

1) Forner A et al. Hepatocellular carcinoma. Lancet 2018;391(10127):1301-14.
2) Niu Y, et al. Contrast-enhanced ultrasonography for the diagnosis of small hepatocellular carcinoma: a metaanalysis and meta-regression analysis. Tumour Biology
2013;34(6):3667-74.
3) VogelA, et al. Hepatocellular carcinoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Annals of Oncology2019;30(5):871-3.
4) Galle PR, et al. EASL clinical practice guidelines: management of hepatocellular carcinoma. Journal of Hepatology 2018;69(1):182-236.
5) Omata M, et al.Asia–Pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update. Hepatology International 2017;11:317-70
6) HeimbachJK,, et al. AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology 2018;67:358-80.
7) Macaskill P, et al. Chapter 10: Understanding meta-analysis Draft version (13 May 2022) for inclusion in: Deeks JJ, Bossuyt PM, Leeflang MM, TakwoingiY, editor(s). Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy Version 2. London: Cochrane.
8) Whiting PF, Ret al. QUADAS-2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Annals of Internal Medicine 2011;155(8):529-36.
9) McMaster University (developed by Evidence Prime) GRADEpro GDT. Version accessed 26 January 2022. Hamilton (ON): McMaster University (developed by Evidence Prime). Available at gradepro.org.





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Disclosure

nothing to disclose

Introduction

Helicobacter pylori (H. pylori) infection has a high prevalence (44.8%) in China and is an important risk factor of gastrointestinal diseases including gastric cancer. Bismuth quadruple therapy (BQT; bismuth + acid suppressant + 2 antibiotics [ABs]) is the currently recommended first-line regimen for H. pylori in China. Increasing AB resistance poses a vital challenge and remarkably reduces the eradication rate (ER) from 95% to 80% globally and 89% to 78% in China. Real-world ER analysis assessed only quadruple therapy in a few single centers and did not focus on different antibiotic combinations and other different regimens.

Aims & Methods

This study was designed to evaluate the diagnosis and treatment pattern of H. pylori infection and the effectiveness of eradication therapy in real-world settings in China. In this retrospective, multicenter study (NCT05073367), de-identified patient data were extracted from the electronic medical records database of 3 hospitals between January 1, 2019, and March 31, 2021. Patients aged ≥18 years with a record of H. pylori infection diagnosis were included. Here we presented the eradication rate of different treatment regimens and the eradication rate of different years with different treatment regimens.

Results

A total of 1426 patients received ET with efficacy evaluation duration＞4 weeks after the eradication therapy and the total eradication rate was 72.09% (n=1028). Most patients (80.36%; n=1146) received standard BQT with an ER of 76.70% (n=879). 158 patients (11.08%) received dual therapy (ER=56.96%; n=90) and 122 patients (8.56%) received triple therapy (ER=48.36%; n=59). Compared with triple and dual therapies, BQT was the predominant regimen in all the years with an ER of 77.86%, 67.64%, and 82.78% in 2019, 2020, and 2021, respectively. The ER of dual therapy was 50% in 2020 and 61.22% in 2021. The triple therapy ER showed a decreasing trend with 78.57% (n=11), 46.25% (n=37), 39.29% (n=11) from 2019 to 2021. Among the BQT regimens, amoxicillin plus furazolidone based regimens showed a higher ER (87.44%; n=181), while the ER of amoxicillin plus levofloxacin, amoxicillin plus clarithromycin based BQT was 77.94% (n=159) and 76.07% (n=391), respectively. Amoxicillin plus furazolidone based BQT showed a higher ER of 87.30%, 83.02%, and 90.11% in 2019, 2020, and 2021 respectively (Table 1).
Table 1. Eradication rate of H. pylori positive patients based on the type of eradication therapy

Conclusion

BQT-based regimens were predominantly prescribed for H. pylori management and the current H. pylori treatment regimens have a suboptimal eradication rate in the real-world settings.

Disclosure

The study was funded by Takeda China. Wensheng Pan, Yan Zhao, and Hongwei Xu have no conflicts of interest. Pengfei Li, Fang Zhou, and Li Xie are employees of Takeda, and they hold Takeda stock options. Medical writing for the development of this abstract was provided by Swathirajan CR, PhD, and Kusuma Kumari G, PhD, of Indegene Private Limited, and funded by Takeda China. Authors retained full control of the abstract content.

Clinical Case Summary

Introduction: While endoscopic retrieval of gastric bezoars has been described involving various instruments and adjuncts, there is no consensus about the management of large non-obstructing gastric trichobezoars¹. This case report describes how a novel endoscopic device primarily developed to resect recurrent or scarred gastrointestinal lesions or pancreatic necrosis, was used to safely remove a large gastric trichobezoar after unsuccessful attempts with standard endoscopic adjuncts.
Case report: A 19-year-old female presented to our ED with CT-proven trichobezoar within the gastric lumen, measuring 123 x 51 mm (image 1).
An initial attempt at endoscopic removal was performed under general anaesthesia. Despite the use of multiple standard instruments (hot and cold snares, biopsy forceps, argon plasma coagulation, and endoscopic scissors) the congealed trichobezoar could not be sufficiently fragmented for removal.
A decision was made to repeat the procedure using EndoRotor™ (Interscope Inc, Whitinsville, Massachusetts), an endoscopic ‘morcellator’ device (image 2), which we have used to safely resect large or scarred, recurrent colorectal and duodenal polyps². The device allowed us to make dents in the trichobezoar, which facilitated the use of hot snares for complete fragmentation and retrieval via Roth net. Our novel use of this for trichobezoar removal was assisted by a team from EndoRotor.
Conclusion: We report the use of this new endoscopic technique to remove a large trichobezoar, which would otherwise have had to been removed surgically. Apart from reduced therapeutic morbidity, this approach facilitated a shorter hospital stay and quicker return to normal activity for our patient, compared to surgical intervention.

References

1. Gorter, R. R., Kneepkens, C. M. F., Mattens, E. C. J. L., Aronson, D. C., & Heij, H. A. (2010). Management of trichobezoar: Case report and literature review. In Pediatric Surgery International (Vol. 26, Issue 5, pp. 457–463). https://doi.org/10.1007/s00383-010-2570-0
2. Emmanuel A, Williams S, Gulati S, Ortenzi M, Gunasingam N, Burt M, Ratcliff S, Hayee B, Haji A. Incidence of microscopic residual adenoma after complete wide-field endoscopic resection of large colorectal lesions: evidence for a mechanism of recurrence, Gastrointestinal Endoscopy, (Volume 94, Issue 2, 2021, Pages 368-375). https://doi.org/10.1016/j.gie.2021.02.010.

Introduction

Diverticular disease of the colon is one of the most common diseases in Western world. Despite in the natural history in most of cases diverticulosis remains asymptomatic or manifests with mild abdominal pain, complications may occur. Bleeding from diverticula is one of the most common complications and, despite it is usually a self-limiting event, it may lead to anemia or shock. Among the endoscopic interventions for active bleeding, direct or indirect clipping of the diverticulum is the most diffuse one. However, it has been hypothesized that endoscopic band ligation (EBL) may be more effective, since it may improve the chance to close the bleeding vessel, with a better outcome on long term. Therefore we performed a meta-analysis comparing clipping versus EBL for diverticular bleeding.

Aims & Methods

Literature search on main databases (PubMed, Web of science, SCOPUS, EMBASE) was performed in November 2022. Studies comparing clip versus EBL for acute diverticular bleeding were selected. We excluded case series, abstract and articles not written in English. The following outcomes were analysed: short term effectiveness, early rebleeding, tardive rebleeding and need for surgery or radiologic embolization. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculate according to Mantel-Haenszel method. Heterogeneity was estimated by I² statistic with chi square test, and, if present, a random effect model was used, otherwise a fixed one was adopted.

Results

Seven studies were selected, overall enrolling 2322 patients (979 in EBL and 1343 in clip groups). Immediate haemostasis was achieved in the EBL and clipping group respectively in the 96.8% and 96.5% (OR=0.94, 95% CI 0.59-4.19, p=0.79). Early rebleeding was observed more frequently in the clipping (25.0%) than in the EBL group (11.8%), with an OR=0.40 (95% CI 0.32-0.51, p<0.001). Similarly, tardive rebleeding was more common in the clipping arm (37.4%) than in the EBL (24.5%), OR=0.39, 95% CI 0.22-0.68, p=0.0001. Patients receiving clipping needed more frequently salvage surgery or embolization than EBL (1.48% versus 0.53%, OR=0.40, 95% CI 0.17-0.93, p=0.03).

Conclusion

Despite EBL and clip have similar effectiveness in achieving immediate haemostasis, EBL showed better effectiveness in maintaining it on longer interval times, with less probable need for major surgical/radiologic interventions.

Introduction

Necrotizing pancreatitis with walled-off necrosis (WON) is associated with severe morbidity and substantial mortality. Vascular complications such as pseudoaneurysm, arterial erosion, and especially thrombosis of the splanchnic veins are all associated with acute pancreatitis (AP). However, the occurrence and clinical outcome of vascular manifestations in patients developing WON are poorly described. We aimed to describe vascular complications in a well-defined cohort of consecutive patients endoscopically treated for symptomatic WON.

Aims & Methods

Four hundred and nine patients treated endoscopically for their pancreatic fluid collection during a 10-year period were assessed for inclusion. Patients with pseudocysts, < 18 years, concomitant malignant disease and/or procedure-related bleeding were excluded. A total of 290 patients were eligible for analysis.
Vascular complications included bleeding and thromboembolic events. Thromboembolic complications were defined as confirmation of thrombus in one of the splanchnic veins on contrast-enhanced computed tomography scan (CECT). Bleeding complications were defined as clinical bleeding necessitating intervention, including embolization, surgery or transfusion.

Results

The median age was 59 years (range 18-84), and 57% were males. Gallstones were the etiology in 47%, alcohol in 20%, and post-ERCP pancreatitis in 14%. In 14% of the cases, the etiology was unknown. Infection was the main indication for intervention (92%), followed by gastric outlet obstruction (6%) and pain (2%). The average time from debut of symptoms to index procedure was 35 days (range 6-89). The average duration of hospital admission was 89 days (range 21-286). The overall in-hospital mortality was 14%, and need for admission to intensive care unit (ICU) was 35%.
In total, 87 (30%) patients developed vascular complications of which 53 (18%) were thromboembolic, 34 (12%) bleeding, and nine patients (3%) developed both thromboembolic and bleeding complications.
The portal vein was most affected (34%), followed by the splenic vein (28%) and the superior mesenteric vein (23%). Two or all three splanchnic veins were affected in 15%. The majority (81%) of thromboembolic complications occurred before the index procedure. Development of splanchnic venous thrombosis was not associated with in-hospital mortality (13% vs. 14%, p=1.0) or need for ICU admission (38% vs. 34%, p=0.64). None of the patients with splanchnic vein thrombosis developed variceal bleeding during follow-up.
The splenic artery was the most common cause of bleeding (32%), followed by the gastroduodenal artery (24%) and the left gastric artery (12%). In five cases, the source of the bleeding could not be identified. All patients received blood products, 23 patients were treated with arterial embolization and 4 patients with surgery. Seventy seven percent of the bleeding complications occurred after the index procedure. The need for ICU (59% vs. 32%, p=0.003) and in-hospital mortality (38% vs. 11%, p<0.0001) were significantly higher in patients with arterial bleedings as compared to patients without.

Conclusion

Vascular complications are common in WON patients. The timing of occurrence seems distinct, as the vast majority of thromboembolic complications occur before index endoscopic intervention, while bleeding complications mainly occur after. While arterial bleedings are linked to increased morbidity and in-hospital mortality, thromboembolic complications are not associated with a poor short- or long-term clinical outcome.

Clinical Case Summary

Muir-Torre syndrome (MTS) is a rare autosomal-dominant genodermatosis characterized by sebaceous neoplasms and multiple visceral malignancies.
A 72-year-old man was admitted to our Emergency room for multiple episodes of lower gastrointestinal bleeding. His personal history was characterized by the diagnosis of MTS. In the previous years he underwent surgery several times, first for distal esophagectomy and total gastrectomy for adenocarcinoma pT3N0, then excision of right and left thigh cancers, atypical left hemicolectomy for adenocarcinoma pT3N0 and partial transversal colectomy for cancer. All of these operations caused anatomical changes and significant non-cirrhotic portal hypertension. At blood test acute severe anemia was found. Esophagogastroduodenoscopy and ileo-colonscopy revealed normal esophageal-digiunal anastomosis and blood in the colon without finding an active source of bleeding. Secondly, abdominal angio-CT scan showed a varix of periumbilical collateral circulation bulging into the ileal lumen, without signs of active hemorrhage. A multidisciplinary team (endoscopists, interventional radiologists and surgeons) evaluated this patient's condition. The surgical technique was not feasible due to post-operative morphological and vascular changes. The radiologists were also unable to perform transjugular intrahepatic portosystemic shunt and embolization for the same reasons. An antegrade double balloon enteroscopy was carried out to identify and stop the bleeding, but it failed. As a result, the source of the ematic loss was not discovered because it was impossible to completly examine the small bowel due to a severe adverse syndrome and the patient eventually died. Bleeding from ectopic varices is a rare and a life-threatening situation. This is one of the rare case describing ileal bleeding varices in a patient with the rare MTS syndrome.
Image: ANGIO-CT SCAN: varix of periumbilical collateral circulation bulging into the ileal lumen

References

Bhaijee F, Brown AS. Muir-Torre syndrome. Arch Pathol Lab Med. 2014 Dec;138(12):1685-9. doi: 10.5858/arpa.2013-0301-RS. PMID: 25427047.
Haddad A, Beji H, Chaker Y, Maghrebi H, Jouini M, Kacem M. Surgical treatment for bleeding ileal varices: A case report. Int J Surg Case Rep. 2021 Nov;88:106573. doi: 10.1016/j.ijscr.2021.106573. Epub 2021 Nov 3. PMID: 34753100; PMCID: PMC8585655.