Introduction

Benign pancreatic disorders pose significant challenges in diagnosis, treatment, and management due to their complex nature and diverse etiology. As the prevalence of pancreatic diseases continues to rise, the demand for specialized care and expertise becomes imperative.
Thus the Section of Interdisciplinary Pancreatology (SIP) has been launched in 2023 at Ulm University Hospital to manage a broad spectrum of pancreatic disorders, encompassing cystic pancreatic lesions, autoimmune pancreatitis and IgG4-related disease (IgG4-RD), and all types of chronic pancreatitis.
Here, we will present insights from two years of experience within this unit, focusing on the disease spectrum, the impact of a multidisciplinary board structure, and the direct advantages of Patient-Reported Outcome Measures (PROMs) in enhancing patient care.

Aims & Methods

To basically show the structure of an interdisciplinary section of pancreatoloy and emphasise resulting advantages and chances in pancreas care. Moreover, descriptive analyses from PROMs, impact on decision making and paths will be shown.

Results

The structured implementation of the SIP created a level of interdisciplinarity that has not been achieved before. Thus collaborative efforts resulted in relevant changes of daily-patient care and patient paths. This is assessed and further shown by the integration of PROMs that are continuously recorded. By systematically collecting patient-reported data on symptoms, functional status, and treatment outcomes, the division gains valuable insights into the patient experience and treatment efficacy and allows patient centered therapy management. Specifically by the integration of a dedicated multidisciplinary board to review cases of benign pancreatic disorders, consensus-driven decision-making optimized diagnostic accuracy and therapeutic planning, fostering individualized approaches. One of these successful approaches that has been established are high numbers of hybrid procedures in robotic enucleation of pancreatic cysts.

Conclusion

In conclusion, our two-years experience in a division of interdisciplinary pancreatology underscores its efficacy in addressing the diverse array of pancreatic disorders. Through collaborative decision-making, regular case reviews, and the integration of PROMs, the SIP exemplifies a patient-centric approach to pancreatic care that prioritizes clinical excellence, interdisciplinary collaboration, and continuous quality improvement.

Introduction

This paired biopsy study aimed to investigate the predictive value of various non-invasive scores for identifying the temporal evolution of hepatic fibrosis in patients with non-alcoholic fatty liver disease (NAFLD).

Aims & Methods

A total of 69 patients with NAFLD who had undergone two paired liver biopsies (mean interval: 21.3 ± 9.7 months) were examined. Fibrosis progression and regression were defined as an increase or decrease of at least one stage in fibrosis between the initial and second biopsy. Fibrosis-4 index (FIB-4), NAFLD Fibrosis Score (NFS), Agile 3+ score, Agile 4 score, and FibroScan-AST (FAST) score were calculated at the time of the initial biopsy.

Results

Upon comparing the results of paired biopsies, 45% of the participants (n = 31) showed no change in fibrosis, 26% (n = 18) experienced fibrosis progression, and 29% (n = 20) had evidence of fibrosis regression. In multivariable logistic regression analysis, the only independent predictive factor for progressive fibrosis was the FAST score. The odds ratio for progressive fibrosis was found to increase by 19% (95% confidence interval: 8–38%, p < 0.05) with every unit increase in FAST score at the time of the initial biopsy. No independent predictors for fibrosis regression were identified.

Conclusion

Patients with higher baseline FAST scores were more likely to experience fibrosis progression independent of potential confounders. Consequently, FAST could serve not only as a diagnostic tool for screening fibrosis in NAFLD, but also as a prognostic indicator.

Introduction

Piecemeal endoscopic mucosal resection (EMR) vs endoscopic submucosal dissection (ESD) has been a long standing debate in the endoscopic community worldwide with multiple studies done to evaluate the preferred method to manage large colorectal neoplasms. Piecemeal EMR with thermal ablation of the margin has been strongly advocated and reported by certain groups to be a simple, inexpensive and effective technique and this has been preferred widely due to its perceived ease of performance and shorter learning curve.¹ However, close, repeated surveillance colonoscopy is recommended even when the lesion is thought to have been completely resected² as residual tumors can cause interval cancers.³ Some groups, mainly from east Asian countries, have recommended en bloc resection by ESD due to significantly lower risk of local recurrence and precise pathological diagnosis.⁴ But its usage is limited due to concerns about risk of serious adverse events. With improvement in training and devices, colorectal ESD is now being performed by various centers globally. This study aims to report the outcomes of an international, multicenter study on colorectal ESD.

Aims & Methods

Patients who underwent colorectal ESD for lesions greater than 20mm between January 2022 to April 2024 from centers in USA, Japan, and India respectively were included in this study. Recurrent lesions after endoscopic therapy, neoplasms identified in patients with ulcerative colitis, and non-epithelial lesions were included. Primary outcomes were en bloc and R0 resection rate, delayed adverse events (bleeding/perforation), and local recurrence rate. Secondary outcomes were procedure time, lesion size, and pathology. Univariate and multivariate analysis were done to identify the risk factors for primary outcomes.

Results

309 patients (median size, 40(27.5-60)mm; location rectum 52.4%, left colon 26.2%, right colon 21.4%) were involved in this study. The en bloc resection rate was 96.1% and R0 resection rate was 90.3%. 3 patients experienced delayed bleeding which was managed endoscopically. 2 patients underwent surgery for delayed perforation. 6 patients had a local recurrence. 67(23%) patients had intramucosal carcinoma on pathology. Univariate analysis showed lesser procedure time (median(IQR) 145(80-236.25) vs 270(180-300) minutes, P= 0.005) and smaller lesion size (median(IQR) 40(26-56.25) vs 60(40-90) mm, P= 0.004) were significant factors for successful en bloc resection. However, lesser procedure time (median(IQR) 74(29.5-97.5) vs 150(82.5-240) minutes, P= 0.034) led to an increased delayed adverse event rate. Multivariate analysis using Cox regression showed en bloc resection (odds ratio 0.038; 95% confidence interval 0.003-0.421; P= 0.008) was an independent factor preventing local recurrence.

Conclusion

This international, multicenter study with data from three countries shows favorable outcomes for colorectal ESD for large lesions. The high en bloc and R0 resection rate, and low adverse event rate show increased global adaptation to this procedure. Reduced local recurrence is an added benefit. Data from a more centers globally will be valuable to establish ESD as the standard for large colorectal neoplasms.

References

1. Sidhu M, Shahidi N, Gupta S et al. Outcomes of thermal ablation of the mucosal defect margin after endoscopic mucosal resection: a prospective, international, multicenter trial of 1000 large nonpedunculated colorectal polyps. Gastroenterology. 2021 Jul 1;161(1):163-70.
2. Gupta S, Lieberman D, Anderson JC et al. Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020;91:463-485.e5.
3. Rutter MD, Beintaris I, Valori R et al. World Endoscopy Organization Consensus Statements on Post-Colonoscopy and Post-Imaging Colorectal Cancer. Gastroenterology 2018;155:909-925.e3.
4. Ohata K, Kobayashi N, Sakai E et al. Long-term outcomes after endoscopic submucosal dissection for large colorectal epithelial neoplasms: a prospective, multicenter, cohort trial from Japan. Gastroenterology. 2022 Nov 1;163(5):1423-34.

Introduction

In cirrhosis, several prognostic scores have been developed to predict overall and complication-free survival. The MELD (Model for End-Stage Liver Disease), MELD-Na and MELD3.0 scores have been proposed as a criteria for allocating organs.

Aims & Methods

The aim of our study was to assess the performance of these 3 scores for the prediction of overall and complication-free survival in decompensated Tunisian cirrhotic patients.
Methods: We conducted an observational, retrospective study involving all patients with decompensated cirrhosis managed in Gastroenterology department of Taher Maamouri hospital during the period from January 2010 to December 2021. Mortality was assessed using the Kaplan Meier model. The performance of the scores was assessed using the AUROC (Area under the Receiver Operating Characteristic curve).

Results

One hundred and fifty-two patients were included with an average age of 61 years. Viral liver cirrhosis was the most common (65.13%). The mean value of the MELD-Na and MELD3.0 scores was 17.74 and 19.4, respectively. The mean follow-up time was 17.1 months. The rate of complications and short-term mortality was 33.6% and 18.4% respectively.
The AUROC of the MELD3.0 score in predicting of the occurrence of further decompensation was the highest (0.775) compared to those of the MELD and MELD-Na score (0.743 and 0.756 respectively). The cut-off value of the MELD3.0 score in predicting further decompensation was 20 (sensitivity 60.7%, specificity 73.3%).
In the prediction of 3-month mortality, the AUROCs of the MELD, MELD-Na and MELD3.0 scores were 0.786; 0.841 and 0.850 respectively. The cut-off value of the MELD3.0 score was 24 (sensitivity 68%, specificity 88%). A statistically significant correlation was noted between the MELD3.0 score ≥24 and 3-month mortality (p=0.04).

Conclusion

The MELD3.0 score had the best predictive value for the occurrence of further decompensation and short-term mortality in decompensated cirrhotic patients. Those with a MELD 3.0 score ≥24 should be prioritized on waiting lists.