Introduction

Gastric dysplasia in the absence of an endoscopically defined lesion is rare, usually either a false positive diagnosis or a previously unidentified precancerous lesion during esophagogastroduodenoscopy (EGD).

Aims & Methods

The aim of this study was to evaluate factors associated with the presence of an endoscopically visible lesion during follow-up in patients with histologic diagnosis of gastric dysplasia in random biopsies.
Retrospective cohort study including patients referred to our institution for gastric dysplasia detected in random biopsies during EGD (Index EGD). In our institution, endoscopic evaluation was performed with a high-definition endoscope using narrow band imaging (HD EGD-0). If no lesion was detected, endoscopic surveillance (HD EGD-FU) was conducted, depending on the originally detected dysplasia: within 6 months for high grade dysplasia (HGD), 12 months for low grade dysplasia (LGD) or indefinite for dysplasia (IFD).

Results

Regarding Index EDG, from a total sample of 96 patients, most patients had LGD (87.4%), 10 patients had IFD (10.4%) and 2 HGD (2.1%), while the location of the dysplasia was the corpus in 8 patients (8.3%), the antrum in 65 (67.7%) and both in 23 (24%).
During the HD EGD-0, 5 (5.2%) presented with an endoscopically visible lesion, while 10 lesions (10.4%) were identified during HD EGD-FU; 80% of the identified lesions were in the antrum.
Patients with Helicobacter pylori infection identified at Index EDG were 8 times more likely to have an endoscopically visible lesion on HD EGD-FU (OR 8.000, 95%CI 1.588-40.299, p=0.012). Additionally, patients with a regular alcohol consumption (≥25 grams daily) were 4 times more likely to have an endoscopically visible lesion on HD EGD-FU (OR 4.063, 95%CI 1.048-15.748, p=0.047). In fact, both Helicobacter pylori infection identified at Index EGD, and regular alcohol consumption were independent predictors of the presence of gastric lesion on HD EGD-FU in binary logistic regression (OR 9.284, 95%CI 1.724-49.979, p=0.009 and OR 5.025, 95%CI 1.136-22.222, p=0.033, respectively).
The grade of dysplasia and location of the biopsies with dysplasia were neither associated with the presence of lesions during follow-up, nor family history of gastric cancer.

Conclusion

The presence of an endoscopically visible lesion occurred in 15.6% of patients with the previous histologic diagnosis of gastric dysplasia in random biopsies and most lesions were identified in the HD EGD-FU. Both Helicobacter pylori infection identified at Index EGD, and regular alcohol consumption were significant predictors of the presence of gastric lesion on HD EGD-FU.

Clinical Case Summary

We describe a case of an 80-year-old woman with a history of bronchiectasis, nasal polyps, and chronic sinusitis who presented to the emergency department with diarrhea(>10 bowel movements/day),abdominal pain and estimated weight loss of 6 kg over one month. She was previously treated with antiparasitics without clinical improvement. Laboratory tests showed peripheral eosinophilia(10,400/mm3 eosinophils, 51.4% of total leukocytes). Viral serologies and autoimmune study were negative. Microbiological and parasitological analyses of stool samples were negative too. Immunoglobulin E levels were elevated. Abdominal computed tomography(CT) revealed thickening of the rectal ampulla and sigmoid colon. Upper gastrointestinal endoscopy did not show any abnormalities, but rectosigmoidoscopy revealed colorectal mucosa with millimetric whitish dots, some scattered erosions, and a 20 mm ulcer in the distal rectum that was biopsied. Histological evaluation showed inflammatory changes with predominance of eosinophilic polymorphonuclear cells(>50/field). Bone marrow study showed eosinophilic myeloid hyperplasia without blasts. No cytogenetic abnormalities were identified on chromosomal analysis. During hospitalization, she developed pruritic erythematous macules on the sacral region and inner thighs that gradually improved with topical steroids. Idiopathic hypereosinophilic syndrome with gastrointestinal involvement and possible cutaneous and pulmonar, was assumed. Prednisolone 40 mg/day was started with clinical and laboratory improvement, with complete resolution of peripheral eosinophilia. The diagnosis of idiopathic hypereosinophilic syndrome is a challenge because it is a diagnosis of exclusion and manifests in various ways depending on the affected system, with gastrointestinal involvement being possible, as in the case presented here. Recognition and early initiation of appropriate treatment can improve the survival and quality of life of these patients.

Introduction

Endoscopic Retrograde Cholangiopancreatography (ERCP) is pivotal in managing complex biliary strictures due to various causes like Cholangiocarcinoma (CCA), Primary Sclerosing Cholangitis (PSC), and mass-related intrahepatic strictures. Traditional ERCP relies on two-dimensional (2D) X-ray imaging, which often presents challenges in accurately localizing and selectively cannulating specific intrahepatic ducts. This study aims to assess the feasibility and effectiveness of three-dimensional (3D) fluoroscopic ERCP in diagnosing and treating complex biliary strictures.

Aims & Methods

We conducted a prospective pilot study, approved by the Institutional Review Board. Adult patients scheduled for ERCP for complex biliary strictures were enrolled. Exclusions included inability or unwillingness to consent, existing percutaneous biliary drainage, or unfeasible selective trans-papillary biliary cannulation.
Performance of 3D ERCP Patients were positioned on a 3D fluoroscopic table. ERCP followed standard protocols, with high-volume contrast injections opacifying bile ducts. After achieving full biliary tree opacification, a balloon was inflated in the distal bile duct in preparation for 3D imaging. To minimize radiation exposure to staff, the endoscope was fixed in a holder, and the room was evacuated before 3D image acquisition. These images were reconstructed to produce detailed 3D visuals of the target area, aiding real-time therapeutic maneuvers like selective intrahepatic duct cannulation.
Data Collection and Analysis Data included continuous variables (mean ± standard deviation) and categorical variables (percentages). Radiation exposure was quantified separately for ERCP and 3D reconstruction, using thermoluminescent dosimeters. Results were reported as Effective Surface Dose (ESD) in mGY and Dose Area Product in mGY.cm^2.

Results

Eighteen patients (median age 66.6) underwent 3D ERCP. 40% had a malignant biliary structure etiology, with 50% showing both intrahepatic and extrahepatic bile duct involvement. 3D reconstruction facilitated successful selective wire cannulation in 80% of cases, previously unachievable with conventional ERCP. One case provided crucial imaging for liver resection planning. The additional radiation dose was 16.44 mGY.cm².

Conclusion

This pilot study proves the feasibility of 3D ERCP in managing complex biliary strictures. This first-of-its-kind study highlights the utility of 3D reconstruction in ERCP. While significantly aiding selective intrahepatic duct cannulation and surgical planning for cholangiocarcinoma resections, it doubles the procedure's radiation exposure, potentially raising cancer risk to 1 in 1000. However the dose needed is significantly lower the IR guided biliary interventions.Further larger studies are required to evaluate the clinical efficacy of 3D ERCP.

Introduction

Current endoscopic ultrasound technologies (EUS) are suboptimal in the assessment of pancreatic cystic lesions (PCLs). We developed a new through-the-needle brush, the "loop brush", to improve the cellular yield, and thereby sensitivity, of EUS fine needle aspiration (EUS-FNA) of pancreatic cysts.

Aims & Methods

We aim to evaluate the "loop brush" safety, robustness, and efficacy.
We performed an in-vivo randomized controlled trial in pigs using artificial cysts. In one group, the loop brush was deployed through a 22G EUS-FNA needle into the cysts. In the control group, cystic punction was performed with standard EUS-FNA. Loop brushes were visually inspected post-procedure. Cytological assessment, cell counting, and hemoglobin analysis were performed in samples from both groups.

Results

Artificial cysts (n=114) were punctured in six pigs, 57 in each group. Neither adverse events nor significant device malfunction occurred during loop brushing. Samples collected with the brush had non-detectable concentrations of hemoglobin in 72% (41/57) of cases, and 26% (16/57) had less than 0.6 g/dL, with no significant difference to the controls (p=0.32). Brushing cell counts were associated with significantly increased cell counts (11.7× median difference, p<.0001). Cytological smears
were diagnostic in 77% of cases in the brushing group, while 54% in the control group (p=0.01, Fisher’s exact test; p=0.006, Chi-square test).

Conclusion

The new loop brush procedure appears to be safe, causing neither significant bleeding nor device malfunction. Samples obtained with the loop brush were suitable for cytological analysis and showed significantly higher cell yield than controls. Further clinical studies are warranted.

References

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Disclosure

FM, WW, UA, NR, and FBS have patent applications for the brush technology and are co- founders of Lucky LoopMedical AB, a company commercializing technology for improved sampling in EUS-FNA. UA has received a research grant from Boston Scientific and is a consultant to Boston Scientific, Medtronic, and Ambu. IS declares no conflict ofinterest.

Introduction

The enhanced recovery after surgery (ERAS) protocol is an evidence-based standardised multimodal programme formulated to reduce surgical stress and optimise recovery after surgery. The ERAS represents the best care practice for patients undergoing colorectal surgery. To ensure high compliance with active ERAS elements, patients must be educated to actively participate in the perioperative care pathway. ERAS protocols were originally designed to treat patients with CRC, only few studies have assessed this protocol in IBD patients.

Aims & Methods

The aim of this study was to investigate the adherence to ERAS in IBD patients. This retrospective study enrolled adult patients who underwent elective colorectal surgery and the ERAS protocol at our institute between May 2020 and December 2022. The patients were divided into IBD and non-IBD group. Data on medical history were collected from electronic health records.Preoperative, intraoperative, and postoperative data were collected for each procedure using a self-reported mobile application. Adherence was calculated for at least 75% of active ERAS items. Chi-square test was used to compare categorical variables.

Results

619 patients, 492 non-IBD and 127 IBD, were enrolled. The overall adherence to ERAS protocol items was similar between the two groups (84% vs 82%, p 0.2). Adherence was evaluated during the three ERAS phases in the groups: preoperative (92% vs 90%, p 0.11), hospitalization (63% vs 62%, p 0.8), post-discharge period (96% vs 93%, p 0.2). Moreover, focusing on the preoperative ERAS items adhrence, there were significant difference between non-IBD and IBD group in nutritional optimization (84% vs 67%, p <0.001) and smart communication (93% vs 89%, p 0.002). No difference were reported in the patient’s prehabilitation adherence (74 % vs 71%, p 0.4).

Conclusion

Introduction

Hemorrhoidal disease (HD) is the most common pathology in proctology, with an estimated prevalence of between 4.4% and 39%. It can be managed in a variety of ways: hygienic-dietary measures, medical, instrumental or surgical treatment. The latter is considered especially after failure of medical and instrumental treatment.

Aims & Methods

Aims : The aim of our study is to report our experience with Milligan and Morgan technique in the management of hemorrhoidal disease.

Materials and methods: This was a monocentric retrospective descriptive-analytical study conducted over a 12-year period: from January 2011 to January 2023. The data studied were age, sex, clinical manifestations, stage of HD on proctological examination and therapeutic data. All patients who underwent Milligan and Morgan hemorrhoidectomy (MMH) and presented with stage IV and III hemorrhoids (after failure of instrumental treatment) were included in our study. Excluded were asymptomatic patients, patients with surgical contraindications and other stages treated by non-surgical means. The statistical study was carried out using IBM-SPSS 20.0 software. The chi-2 test was used to compare categorical variables.

Results

468 patients were enrolled during the study period. The mean age of this population was 41 years (22-71). The sex ratio M/F was 2,1. Clinical expression was dominated by rectal discharge in 246 patients (74%), proctalgia in 132 patients (28%), anal pruritus in 119 patients (25%) and anal oozing in 56 patients (12%). Proctological examination revealed stage IV haemorrhoids in 201 patients (43%) and stage III haemorrhoids in 267 patients (57%). 25 patients (5.3%) had an associated anal fissure. Anemia was present in 341 patients (72.8%), with a mean hemoglobin value of 7.8 g/dl. Transfusion was required in 65 patients (14%) who presented with severe anemia of less than 7g/dl. Colonoscopy was indicated in 87 patients (18.5%) over the age of 45 with rectal bleeding, and in 42 patients (9%) with a history of digestive cancer. Milligan and Morgan's indication was stage III hemorrhoids with severe anemia in 65 patients (14%), after failure of infrared photocoagulation in 194 patients (41.4%); after failure of HAL-RAR treatment n=8 (1.7%) and stage IV hemorrhoids in 201 patients (43%). The procedure performed was a hemorrhoidectomy.An open pedicle MMH type was performed. Patients with an associated anal fissure (5.3%) underwent the Bellan procedure in addition to hemorrhoidectomy. Immediate post-operative complications included post-operative pain in all our patients, urinary retention in 31 patients (6.6%), significant post-operative bleeding in 2 patients (0.5%) treated by electrocoagulation in the OR, and minimal post-operative bleeding in 117 patients (25%) treated by compression bandaging. The latter was reported in 43 patients (36.7%) with stage III hemorrhoids and 74 patients (63.2%) with stage IV hemorrhoids. This difference was statistically significant (p<0.001). Late complications included delayed healing in 9 patients (1.9%), 4 of whom were diabetic, anal stenosis in 5 patients (1%), requiring sphincterotomy combined with anoplasty in 3 patients, and finger dilatation in 2 patients. Anal stenosis was reported in 4 patients who did not undergo postoperative digital rectal examination and 1 patient who did. This difference is statistically significant p=0.03.

Conclusion

MMH remains the gold standard for the treatment of hemorrhoidal disease. The results are satisfactory, especially in the long term. Post-hemorrhoidectomy anal stenosis remains the most serious complication.

Clinical Case Summary

We report the case of 20 year old female patient with Crohn's disease who was shifted to Combo therapy (Infliximab + Azathioprine) for failing to reach mucosal healing on Conventional treatment. Quantiferon test, virology panel and a CT chest were negative prior to therapy. After one year of treatment she presented with high grade fever, weight loss, and abdominal pain. COVID-19 PCR and CT chest were negative. However, quantiferon test was positive. CTE abdomen showed marked thickening and stricture in the ileocecal area. Colonoscopy (Video available) was done to obtain biopsies; serpiginous ulcers with narrowing were noted. Histopathological assessment showed heavy Inflammatory cells with no more specification. A gene Xpert PCR on the tissue biopsy was positive for MTB. Given the septic state of the patient biological therapy was held for the duration of her treatment. She started Anti-TB and improved as the fever subsided and she gained weight. Colonoscopy was re-attempted after 4 months of treatment to confirm resolution (Video available). An impassable fibrotic stricture was noted the biopsy forceps could however be introduced and biopsies were obtained. Gene Xpert test was negative. The patient was started on Ustekinumab monotherapy with good response.
TB infection in patients on Anti-TNF therapy is a well-recognized potential side-effect of these drugs. To the best of our knowledge, this is the first reported case of Ileocecal TB on top of Crohn’s disease. A major challenge was weighing how much of the active inflammation shown in the endoscopy, biopsy and imaging was due to TB infection and how much was because of Crohn's disease activity. The time to re-initiate therapy was difficult given that the patient's bad general condition before starting antimicrobial treatment. While recommendations suggest starting immunosuppressives after 8 weeks of treatment in active tuberculosis, the evidence support this in pulmonary rather than extrapulmonary tuberculosis.