Introduction

Pancreatic cancer (PC) is the fourth-leading cause of cancer-related death, with over 80% of patients having unresectable disease upon diagnosis. Despite opioid treatment, more than 70% of this population is experiencing chronic pain during the disease, along with a plethora of side effects. In the past decades, interventional radiological procedures have gained a significant role in pain management.

Aims & Methods

Our study aims to identify the most effective approach for managing pain in individuals with unresectable pancreatic cancer. We registered the study on PROSPERO (CRD42023477094) and systematically searched five major scientific databases on the 29th of October, 2023. Only randomised controlled trials (RCTs) reporting on adult patients diagnosed with unresectable PC and cancer-related pain undergoing medical or interventional treatment were considered eligible. The main intervention groups were endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN), percutaneous celiac plexus neurolysis (P-CPN), high-intensity focused ultrasound (HIFU), and pharmacological therapy (opioids). Our outcomes of interest were pain, survival, and adverse events. Pooled means and proportions were calculated with 95% confidence intervals (CIs), and a random-effects model was applied.

Results

After title-abstract and full-text article selection, 1644 patients of 21 RCTs were found eligible. The pain was assessed using the 11-point Visual Analogue Scale from randomisation at 4, 8 and 12 weeks to determine its dynamic over time. Pain values at baseline were 6.09 (CI: 4.24-7.94) for EUS-CPN, 6.67 (CI: 5.20-8.14) for P-CPN, 6.57 (CI: 4.98-8.15) for HIFU, and 6.47 (CI: 5.02-7.93) for opioids. At one month, the overall pain score was 1.53 (CI: 0.23- 2.82) for EUS-CPN, 2.21 (CI: 1.43-2.91) for P-CPN and 2.68 (CI: 1.94-3.42) for opioids. At two and three months after randomisation, there was a slow but continuous increase in pain scores for all treatment groups. The median survival time in days was 126.22 (CI: 87.21-165.31) for pharmacological treatment and 86.71 (CI: 62.45-136.88) for P-CPN. Patients receiving only opioids developed more adverse events compared to P-CPN, the most common being nausea, vomiting, and constipation. EUS-CPN had the lowest rate of adverse events.

Conclusion

Our study shows that minimal-invasive pain treatments provide pain control with fewer adverse events associated, with EUS-CPN having the most promising results. However, further RCTs with higher sample sizes are needed to confirm our findings.

References

1. Wong et al., Effect of Neurolytic Celiac Plexus Block on Pain Relief, Quality of Life, and Survival in Patients with Unresectable Pancreatic Cancer - A Randomized Controlled Trial JAMA. 2004; 291:1092-1099
2. Dong et al., Neurolytic Splanchnic Nerve Block and Pain Relief, Survival, and Quality of Life in Unresectable Pancreatic Cancer: A Randomized Controlled Trial, Anesthesiology 2021; 135:686–98
3. Gao et al., A randomized clinical trial of nerve block to manage end-stage pancreatic cancerous pain, Tumor Biol. (2014) 35:2297–2301
4. Kanno et al., Efficacy of EUS-guided celiac plexus neurolysis compared with medication alone for unresectable pancreatic cancer in the oxycodone/fentanyl era: a prospective randomized control study, Gastrointest Endosc 2020;92:120-30
5. Zhang et al., Effect of Neurolytic Celiac Plexus Block Guided by Computerized Tomography on Pancreatic Cancer Pain, Dig Dis Sci (2008) 53:856–860
6. Lv et al., High-intensity focused ultrasound therapy in combination with gemcitabine for unresectable pancreatic carcinoma, Therapeutics and Clinical Risk Management 2016:12 687–691
7. Li et al., Retrospective analysis of high intensity focused ultrasound combined with S-1 in the treatment of metastatic pancreatic cancer after failure of gemcitabine, Am J Cancer Res 2016;6(1):84-90

Introduction

Thermal ablative methods (such as argon plasma coagulation (APC) and soft tip snare coagulation (STSC) are commonly used to treat polyp margins.

Aims & Methods

We aim to appraise the current literature and compare clinical outcomes between patients with treated (with APC vs STSC) and non-treated EMR margins.
We searched major databases from inception until November 2023 for RCTs comparing EMR of large non-pedunculated colorectal polyps with and without treated margins. Pooled data was analyzed for the primary outcome of recurrence at first screening colonoscopy, as well as adverse events. Analysis was performed using a random effects model and data was reported using 95% confidence intervals (CI).

Results

A total of five RCTs were found which included 1020 polyps (577 in treatment and 443 in control groups). Three studies included treatment with STSC and three studies used APC as the modality for margin ablation. Of included patients, 53% were female and average age was similar between treatment and control groups (65.9 vs 66.1 years). Overall, 71% of lesions were proximal to the splenic flexure. Mean follow up to first colonoscopy and average polyp size were comparable (6.3 vs 6.2 months; 28.2 mm vs 28.0 mm, respectively). Pooled analysis showed that margin ablation was associated with significantly lower rates of recurrence (OR = 0.267, 95% CI 0.18 - 0.4, P< 0.001) with low heterogeneity between studies (I²=0%, P = 0.47). Pooled analysis showed no significant difference between STSC and APC in terms of recurrence (OR = 0.6, 95% CI 0.27 - 1.7, I²=0%, P=0.3) or adverse events (OR = 0.67, 95% CI 0.3 - 1.6, I² 13%, P = 0.46).

Conclusion

Our study shows that ablation of EMR margins is very effective at preventing recurrence at first surveillance colonoscopy. We found no difference between STSC or APC in terms of polyp recurrence or adverse outcomes.

Introduction

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory disorder that often affects multiple organs. Glucocorticoids (GCs) are often used first-line for the treatment of IgG4-RD.¹ Despite their therapeutic benefits, long-term GC use is known to be associated with toxicities that can affect several organ systems.¹ While the association between GC exposure and toxicities has been well characterized in other conditions, little is known about the real-world use of GCs and the associated clinical burden in the context of IgG4-RD.

Aims & Methods

Commercially insured adults (age ≥18 years) diagnosed with IgG4-RD were identified in the IQVIA PharMetrics® Plus database (01/01/2011-06/30/2022) using a validated algorithm. This algorithm considered IgG4-RD-related diagnoses, prescription medication fills, and medical procedures.² The index date was defined as the first observed IgG4-RD-related diagnosis code, and the baseline and follow-up periods were defined as the 12 months before and after the index date, respectively. GC use during the follow-up period was calculated as the total cumulative prednisone equivalent dose divided by 365 days. Patients were classified into two mutually exclusive cohorts based on GC use. The low GC use cohort comprised patients with a mean GC dose of <5 mg/day, including patients with no GC use; the high GC use cohort comprised those with a mean GC dose of ≥5 mg/day. Incident GC toxicities were defined as toxicities with ≥1 diagnosis during the follow-up period and no diagnosis during the baseline period. Demographic characteristics were reported as of the index date; GC use and incident toxicities were reported during the follow-up period. Descriptive comparisons of incident toxicities between cohorts were analyzed using Chi-square tests.

Results

A total of 295 patients with IgG4-RD were identified, with 150 (50.8%) included in the low GC use cohort (mean age 48.9 years, 55.3% female) and 145 (49.2%) in the high GC use cohort (mean age 50.8 years, 45.5% female). In the first year after diagnosis, most patients (84.1%) received ≥1 GC fill, with a mean of 4.1 fills, corresponding to 3.9 months of treatment. Patients in the low GC use cohort received a mean of 1.8 fills, corresponding to 1.4 months of treatment or a mean dose of 1.4 mg/day over the 12-month follow-up period. Patients in the high GC use cohort received 6.4 fills, corresponding to 6.5 months of treatments or a mean dose of 12.0 mg/day over the follow-up period. Higher GC use was associated with higher rates of incident GC toxicities, such that patients in the high GC use cohort had a greater mean number of GC toxicities (1.8 vs. 1.2; p<0.01) and were more likely to have ≥3 toxicities (29.0% vs. 13.3%; p<0.01) than the low GC use cohort. In particular, cardiovascular (29.0% vs. 18.7%; p=0.04), gastrointestinal (29.7% vs. 16.0%; p<0.01), and infectious (31.0% vs. 17.3%; p<0.01) toxicities were more commonly observed among patients with high GC use than low GC use.

Conclusion

In the first year after diagnosis, patients with IgG4-RD experienced a substantial GC burden, as evidenced by nearly half of them exposed to high GC use. Higher GC use was associated with an increased incidence of GC toxicities across multiple organ systems. These findings suggest an unmet need for safe and effective treatments to mitigate prolonged exposure to GCs and improve patient outcomes, particularly in the absence of targeted FDA-approved therapies for IgG4-RD.

References

1. Yasir M, et al. 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK531462/.
2. Wallace ZS, et al. ACR Open Rheumatol. 2022;4(4):371–7.

Disclosure

Z.S. Wallace, E. Serra, A. Guérin, and V.K. Singh have received consulting fees from Amgen Inc.
J. Park, K.R. Patterson, H. Patel are employees of Amgen Inc. and hold stock.

Study and abstract were funded by Amgen Inc.

Introduction

Helicobacter pylori (HP) is regarded as a class I carcinogenic factor and eradication therapy can reduce the risk of gastric cancer. Patients with HP infections are administered with bismuth quadruple therapy (BQT), triple and dual therapies based on their eradication effectiveness. BQT (bismuth + acid suppressants + 2 antibiotics) and dual therapy are both recommended in China now. Comprehensive understanding on the distribution of current eradication therapies is required to identify gaps observed in real-world practice.

Aims & Methods

This multicenter, retrospective, real-world study (NCT05073367) extracted preexisting electronic data including adult patients (aged ≥18 years) with HP infection between January 1, 2019 and March 31, 2021 from 3 hospitals to assess the diagnosis and treatment pattern of HP infection and effectiveness of eradication therapy in China. In this abstract, we reported the distribution of eradication therapies, difference in initiation year for treatment, and treatment duration.

Results

Of the 22,971 eligible patients with HP infection, 13,233 (57.61%) were prescribed eradication regimens. Mean ± SD age of patients with eradication treatment was 43.7 ± 14.0 years; 65.94% of patients had medical insurance; and 54.50% of patients were women.
In patients who received eradication therapy, the BQT therapy was predominantly prescribed (85.39%; n=11301), followed by triple therapy (7.55%; n=999) and dual therapy (7.06%; n=934). Among those receiving BQT, use of amoxicillin + clarithromycin based regimens (38.72%; n=4376) were the most prevalent, followed by amoxicillin +furazolidone (18.35%; n=2074) and amoxicillin + levofloxacin (17.76%; n=2007) based combination regimens. Proportion of patients receiving BQT decreased over years: 97.24% patients in 2019, 79.98% in 2020, and 78.71% in 2021. The proportion of patients receiving dual and triple therapy increased over the years in 2019, 2020, and 2021 were shown in Table 1. A total of 10,903 patients were analyzed according to various treatment durations with the usage of various eradication therapies. Treatment duration is defined as the number of days that prescribed drugs can cover. Out of the three types of treatments, BQT had the highest proportion of 14-day treatment duration at 90.16%, followed by triple therapy at 76.78%, while dual therapy had the least proportion at 14.42%. For treatment duration >14 days, BQT, dual and triple therapy had a proportion of 4.38%, 82.35%, and 17.27% respectively.
Table 1. Distribution of eradication therapy based upon the type and year of treatment initiation

Conclusion

BQT-based regimen for 14 days was the predominant eradication regimens in all therapies, amoxicillin + clarithromycin based BQT was the most prevalent. Use of dual therapy gradually increased with years for HP eradication in the Chinese real-world clinical practice.

Disclosure

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

Introduction

Pouchoscopy is indicated for pouch assessment and surveillance following ileal pouch-anal anastomosis (IPAA) surgery. Annual surveillance is suggested in cases who are at high risk of neoplasia (i.e. Primary Sclerosing Cholangitis (PSC)/ colonic dysplasia/ neoplasia), and 5 yearly in low risk patients^1,2. Biopsies are recommended. With the pressures on endoscopy services continuing we reviewed endoscopy utilisation in our cohort of pouch patients.

Aims & Methods

We searched via health informatics for all patients who underwent IPAA surgery at our centre the Queen Elizabeth Hospital, Birmingham, United Kingdom, from 2012 to 2022. Via case note review, we reviewed indication, timing, presence of high-risk features and pouchoscopy report

Results

56 patients underwent surgery for formation of new IPAA during this study period. The majority were performed were performed from 2012- 2015 (36 cases, 62%). 6 (10%) were undertaken as a single stage procedure, the remainder were 2 stage and 1 (1.8%) was a conversion from an ileo-rectal anastamosis. Indication for IPAA was medically refractory inflammatory bowel disease (IBD) in 48 (86%) cases, colonic dyslpasia in the context of IBD in 5 (9%), and 3 (5%) had an underlying genetic disorder for malignancy e.g. FAP or HNPCC. 16 patients had high risk features (PSC colitis=5, Dysplasia/neoplasia =11), although 2 were referred elsewhere for surveillance.
148 pouchoscopies were performed on this cohort of patients, with an average of 1 pouchoscopy every 3 years from IPAA date (range: 1 pouchoscopy per 0.4 – 10 years). The majority (113, 76%) of procedures were for pouch symptoms e.g. frequency, pain. Biopsies were taken in 98 (66%). Dye spray surveillance was not performed. No biopsy showed pouch or rectal neoplasia, but 73 (74%) showed pouchitis/cuffitis/inflammation.
Despite high resource utilisation, adherence to surveillance protocols remained poor.

Conclusion

This study shows poor implementation of pouch surveillance guidelines yet high use of endoscopy for pouch assessment often without biopsy. Our findings suggest that surveillance for neoplasia is an overlooked component of the care of patients who have under IPAA surgery. Furthermore, there is uncertainty within guidelines about frequency of surveillance particularly in low risk groups, although these patients do have a recognised risk of neoplasia^2,3.
We recommend that endoscopists take biopsies routinely when assessing pouch such as Type C mucosa in the pouch (mucosa exhibiting permanent persistent atrophy and severe inflammation) has a greater propensity for neoplastic changes. In addition, more data is needed to determine the risk of neoplasia in different subgroups of patients who have undergone IPAA surgery, as well as develop robust guidelines on use of endoscopy in pouch management.

References

1 = Derikx LA, Nissen LH, Oldenburg B, Hoentjen F. Controversies in Pouch Surveillance for Patients with Inflammatory Bowel Disease. J Crohns Colitis. 2016 Jun;10(6):747-51. doi: 10.1093/ecco-jcc/jjw035. Epub 2016 Jan 28. PMID: 26822612.
2 = Lamb CA, Kennedy NA, Raine T, et al British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults Gut 2019;68:s1-s106.
3=Samaan MA, Forsyth K, Segal JP, De Jong D, Vleugels JLA, Elkady S, Kabir M, Campbell S, Kok K, Armstrong DG, Penez L, Arenaza AP, Seward E, Vega R, Mehta S, Rahman F, McCartney S, Bloom S, Patel K, Pollok R, Westcott E, Darakhshan A, Williams A, Koumoutsos I, Ray S, Mawdsley J, Anderson S, Sanderson JD, Dekker E, D'Haens GR, Hart A, Irving PM. Current Practices in Ileal Pouch Surveillance for Patients With Ulcerative Colitis: A Multinational, Retrospective Cohort Study. J Crohns Colitis. 2019 May 27;13(6):735-743. doi: 10.1093/ecco-jcc/jjy225. PMID: 30590513.

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.

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.