Introduction

With the increase in the opportunity to follow up patients with risk factors for pancreatic cancer, such as IPMN, using imaging tests, it is generally considered to discontinue follow-up for those who are elderly and not eligible for surgery. There are few studies comparing the group of patients who underwent surgery with those who did not undergo surgery among super-elderly individuals aged 80 years or older.

Aims & Methods

This was a retrospective, single-center study aimed at examining the extension of survival by surgery in healthy super-elderly patients aged 80 years and over with pancreatic cancer. Among the 183 patients diagnosed with histologically confirmed conventional ductal adenocarcinoma of the pancreas at our hospital between April 2011 and March 2021, we targeted 20 cases aged 80 years or older, whose clinical courses were available, and who were considered to be resectable or borderline resectable with an ECOG Performance Status of 0. Of the 20 cases, 11 underwent surgery and 9 did not, and we retrospectively compared the surgery group and non-surgery group.

Results

The age of the surgery group was 83±5 years, while that of the non-surgery group was 88±6 years, which was significantly higher in the non-surgery group. However, there was no significant difference in gender, symptom rate, abdominal pain rate, or blood test results for Alb, AMY, CEA, or CA19-9 levels. Tumor localization was pancreatic head (64%), pancreatic body (18%), and pancreatic tail (18%) in the surgery group, while all cases in the non-surgery group were located in the pancreatic head. All cases in the surgery group were Resectable on CT imaging, and they underwent pancreaticoduodenectomy (73%), distal pancreatectomy (18%), or total pancreatectomy (9%) without NeoAdjuvant Chemotherapy. In the non-surgery group, 89% were Resectable and 11% were Borderline on CT imaging, and the reasons for non-resection were age (45%), patient preference (33%), past medical history (11%), and surgeon's judgment (11%). Chemotherapy was administered in 64% of the surgery group and 67% of the non-surgery group, and second-line or later treatment was administered in 27% of the surgery group and 22% of the non-surgery group. In addition, radiation therapy was administered in 18% of the surgery group. The median survival time (IQR) was 333 (251-426.5) days in the surgery group and 226 (137-728) days in the non-surgery group, which was significantly longer in the surgery group. All cases in the surgery group died of the original disease, while 78% of the non-surgery group died of the original disease and 22% died of cerebral infarction.

Conclusion

Surgery is expected to prolong the survival period even in super-elderly individuals, and imaging follow-up for early detection of pancreatic cancer is important even in super-elderly individuals if they have a surgical tolerance.

Introduction

Pancreatic neuroendocrine tumors (pNETs) are a heterogeneous group of tumors with different treatment options depending on pathological grading, clinical staging, and presence of symptoms related to hormonal secretion. Their classification is made on mitotic count and Ki-67 index.
The current standard for Grading assessment is analysing the material obtained from EUS-guided fine needle aspiration/biopsy (EUS-FNA/FNB). However this technique is not free from adverse events and could be challenging for NETs localization.
The evidence of high grade of fibrosis and microvascular density decrease (MVD) on tumor pathological specimens has led many authors to search for undirected malignant features of pNET extrapolated from non-invasive techniques. The introduction of ancillary techniques, such as second-generation contrast agents (CH-EUS), has improved study of pNET. Particularly, at CH-EUS examination contrast pattern well correlates with behaviour and grading of NETs. However, the use of contrast agents entails a prolongation of procedure time and additional costs. An innovative ultrasound Doppler technique, Detective Flow Imaging EUS (DFI-EUS), involves no additional time or cost as it doesn’t require the administration of contrast agent. There is still no standardisation of this technique and few studies have validated its use.

Aims & Methods

The aim of this study is to evaluate the DFI role in defining NET vascularization and its correlation with CH-EUS. The second aim of the study is to assess DFI role in predicting histological grading.
Single center retrospective analysis on consecutive patients with solid pancreatic lesions who underwent EUS at Therapeutic Digestive Endoscopy Unit of the Fondazione Policlinico Universitario Campus Bio-Medico in Rome.
After activation of DFI, each lesion was observed for at least 30 seconds. Lesions was classified into three grades, according to the degree of vascularisation at DFI: (grade 0 absence of microvascularization of the tumor; grade 1 minimal/isovascularization of the tumor; grade 2 markedly increased microvascularization).
All lesion with final hystological diagnosis of NET were enrolled.
Grading and Ki-67 index of tumors were reported.
Data about lesion’s features and procedure were collected.

Results

From April 2024 to February 2025, 17 patients were enrolled (58.8% male; mean age 57±12 years old). The majority of lesion (53%) were localized in the body of the pancreas and the mean lesion’ s size was 28±20 mm. The final histological diagnosis classified 50% lesions as G1, 38.8% G2 and 5.5% G3.
At the CEH-EUS the 70.6% of lesion showed hyper-enhancement. About the DFI evaluation the 17.6% of lesion was hypo-vascular, 17.6% Iso-vascular and 64.7% was hyper-vascular. There was excellent correlation between DFI characterization of the lesion and the CH-EUS (ICC 0.9)
Among the NET G1, 66.7% were Hypervascular at DFI and 33.3% Isovascular. Among the G2, 71.4% were Hypervascular at DFI and 28.6% Hypovascular. The only G3 lesion was Hypovascular.
There was inverse correlation between the NET grade and the DFI grade (Pearson coefficient -0.56; p 0.02).

Conclusion

DFI-EUS can provide a fast evaluation of the micro-vascularization of pNET with excellent correlation with CH-EUS. Hyper-vascular pattern at DFI correlates with low Ki-67 index.

Introduction

Aspiration Pneumonia is a well described complication of upper digestive endoscopy. However, limited data are available on incidence, risk factors and clinical consequences of post- Endoscopic retrograde cholangiopancreatography (ERCP) aspiration pneumonia (pEP).

Aims & Methods

All consecutive ERCPs performed under anesthesiologist-administered sedation at the Endoscopy Unit of the University of Verona between April 1st 2022 and August 31st 2024 were retrospectively evaluated. Demographical, clinical and endoscopic data were collected.

Results

One-thousand-one-hundred-forty consecutive ERCPs were included. Main indication was malignant biliary stricture and patient’s mean age was 68±13.9 years. Overall incidence of pEP was 2.7%. American Society of Anesthesiologists (ASA) score, presence of active cholangitis before ERCP and performance of endoscopic ultrasound (EUS) and ERCP in the same sedation session were significantly associated to higher risk of pEP at both univariable and multivariable analysis. pEP was an independent risk factor for post-ERCP 30-days-mortality and for prolonged hospital stay.

Conclusion

pEP is a relatively frequent adverse event after ERCP. In patent with high ASA score, active cholangitis and scheduled EUS and ERCP in the same sedation session, preventive medical and/or anesthesiological strategies might be considered. Additional prospective studies are needed to confirm these data.

References

Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Complications of ERCP: a prospective study.
ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
Unrecognised aspiration pneumonitis during enteroscopy: two case report.
Efficecay and safety of therapeutic endoscopic retrograde cholangiopancreatography in patients with native papillae with a performance status score of 3 or 4: a single-center retrospective study.
A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administred sedation.
Increased ERCP-related adverse event from premature urgent ERCP following symptom onset in acute biliary pancreatitis with cholangitis.
Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): results from the prospective multicentre electronic registry of sedation-associated complications.
Deep sedation without intubation for ERCP is appropriate in healthier, non-obese patients.
Comparative efficacy and safety of anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography: a network meta-analysis.
International consensus recommendations for difficult biliary access.
Intraprocedural quality in endosocpic retrograde cholangiopancreatography: e meta-analysis.
Criteria for difficult biliary cannulation: start to count.
Safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography for patients over 90 years of age.
Risk factors for post-endoscopic retrograde cholangiopancreatography complications in very elderly patients aged 90 years or older-no additional risk.

Disclosure

I have no conflict of interest

Introduction

Computer-aided detection (CADe) systems improve adenoma detection rate (ADR). However, there is some concern that the long-term use of CADe systems might lead to a decline in endoscopists’ independent detection skills, particularly their ability to detect lesions without assistance—a phenomenon referred to as "deskilling".

Aims & Methods

This study aims to evaluate the impact of CADe on the learning curve of endoscopists for ADR. This was a propensity score–matched (PSM), prospective, single-center, observational study conducted at a tertiary care hospital from January 2021 to December 2023. CADe systems were installed in half of the endoscopy units, and patients were equally distributed between the rooms. Patients in CADe-equipped rooms were examined using EndoBRAIN-EYE (Olympus Corp, Tokyo, Japan). Patients aged ≥ 20 years scheduled for colonoscopy were included, excluding those with polyposis, inflammatory bowel disease, known polyps, incomplete colonoscopy, emergency cases, previous colorectal surgery, and examination by novices. Endoscopists were classified as high-detectors (ADR ≥ 25%) or low-detectors (ADR < 25%) based on the ADR recorded before CADe implementation. The primary outcome was to evaluate the learning effect of CADe using cumulative summation (CUSUM) analysis based on ADR during both CADe and non-CADe procedures to assess skill acquisition and transfer. The CUSUM scores were calculated from the acceptable probability of failure and unacceptable probability of failure. Acceptable and unacceptable ADR were defined as 40% and 30% for high detectors, and 35% and 25% for low detectors, respectively. Performance was judged based on the boundary lines (h0 and h1): acceptable if the CUSUM plot fell below h0, unacceptable if it went above h1, and inconclusive requiring further observation if it stayed between these boundaries. The secondary outcomes included ADR, advanced adenoma detection rate (AADR), and sessile serrated lesion detection rate (SSLDR). The study received ethics approval (no.19H072) and complied with the Declaration of Helsinki.

Results

Out of 5,717 patients initially enrolled, 4,712 patients (2,356 in CADe group and 2,356 in non-CADe group) were analyzed after PSM for known factors (age, sex, indication, and bowel preparation). During CADe-assisted procedures, both high-detectors and low-detectors showed patterns below the acceptable performance line (h0), indicating improved adenoma detection performance with AI support. However, during non-CADe procedures, the patterns diverged significantly. For high-detectors, their CUSUM plots consistently fell below the acceptable performance line (h0) over time during non-CADe colonoscopies, indicating that they successfully acquired and maintained improved adenoma detection skills even without AI assistance. In contrast, the CUSUM plots of the low-detectors remained between the acceptable (h0) and unacceptable (h1) limits throughout the study period, showing no significant change in learning trajectory during non-CADe procedures. The CADe group had a significantly higher ADR (40.5% [95% CI: 38.5-42.5%]) compared to non-CADe group (32.4% [95% CI: 30.5-34.4%]; p < 0.001). SSLDR was also significantly higher in the CADe group (6.9% [95% CI: 5.9-8.0%] vs. 4.5% [95% CI: 3.7-5.4%]; p = 0.001), while AADR showed no significant difference (4.1% [95% CI: 3.4-5.0%] vs. 4.7% [95% CI: 3.9-5.6%]; p = 0.39).

Conclusion

The implementation of the CADe system did not result in deskilling regarding adenoma detection.

Disclosure

The conflict of interests were following: Shin-ei Kudo and Masashi Misawa received speaking honoraria from Olympus Corporation and have an ownership interest of the products of Cybernet Systems. Kensaku Mori received research grants from Cybernet Systems, Morita Mfg, Atom Medical Inc, and Asahi Intecc. Additionally, Kensaku Mori serves as a Technical Advisor for Sanyu Industry. Tetsuo Nemoto received a research grant from Olympus Corporation for other studies. Other authors have nothing to declare.

Introduction

Chronic liver disease remains one of the most common causes for hospital admission and is associated with high morbidity and mortality rates. Timely and adequate management within the first 24 hours is crucial for improving clinical outcomes in cases of decompensated cirrhosis. This study aimed to evaluate the impact of implementing a care bundle checklist during the first 24 hours of hospital admission on management and outcomes of decompensated cirrhosis.

Aims & Methods

We developed an adapted care bundle (based on the BSG/BASL care bundle, AASLD quality measures proposal, Baveno VII consensus, and EASL guidelines) and compared two patient groups from two Portuguese hospital centers: Group-A (retrospective, pre-care bundle implementation) and Group-B (prospective, post-care bundle implementation).

Results

A total of 224 patients (Group-A: 148; Group-B: 76) were included. More than one decompensation was observed in 118 patients (52.7%), and 69 patients (30.8%) were experiencing their index hospitalization for liver decompensation. Regarding etiology, alcoholic liver disease was the most common (n=200; 89.3%). The groups were similar in terms of gender, age, length of hospital stay, and Child-Pugh and MELD-Na scores at admission. The most common decompensations were gastrointestinal bleeding (n=91; 40.6%), ascites (n=75; 33.5%), and hepatic encephalopathy (n=72; 32.1%). Group B was more likely to present with multiple decompensations at admission and exhibited significantly higher rates of acute kidney injury, hepatocellular carcinoma, acute-on-chronic liver failure, and portal vein thrombosis (p<0.05). Following care bundle implementation, we found significant improvements in patient care. At admission, patients were significantly more likely to undergo urine and blood cultures, chest X-ray, and abdominal ultrasound (p<0.05), receive diagnostic paracentesis (p<0.05), and have an accurate alcohol history documented (p=0.04). During admission, Group-B was significantly more likely to be prescribed lactulose for encephalopathy prophylaxis, vasopressor therapy for gastrointestinal bleeding, and venous thromboembolism prophylaxis, as well as undergo nutritional assessment (p<0.05). While in-hospital mortality rates were similar (4.7% vs. 5.3%; p=1), 6-week mortality rates (8.8% vs. 3.9%; p=0.01) and 3-month readmission rates (31.1% vs. 15.8%; p=0.02) were significantly lower in the post-intervention cohort.

Conclusion

The implementation of a standardized care bundle was associated with higher rates of appropriate investigation and treatment within the first 24 hours of hospital admission and improved patient outcomes, reducing 6-week mortality and 3-month readmission rates.

Introduction

The cornerstone of acute cholangitis treatment is antibiotic therapy combined with biliary drainage. The Tokyo Guidelines 2018 provide severity grading criteria that help predict prognosis and identify patients requiring early biliary drainage. While mild cholangitis can often be managed initially with antibiotics alone, moderate and severe cases typically require early and emergent drainage, respectively. Our aim is to explore factors influencing the timing of ERCP in acute cholangitis and its impact on clinical outcomes.

Aims & Methods

This retrospective single-center cohort study included patients diagnosed with acute cholangitis who underwent ERCP between March 2022 and March 2023 in a tertiary hospital with ERCP. Diagnosis and severity grading were based on the Tokyo Guidelines 2018. Descriptive and statistical analyses were performed to evaluate patient characteristics, severity classification, timing to ERCP and related clinical outcomes.

Results

A total of 104 patients underwent ERCP for acute cholangitis; 55 were female (52.9%) and the median age was 77 years. Based on the Tokyo 2018 criteria, 28 patients (26.9%) had grade III cholangitis, 52 (50%) grade II and 24 (23%) grade I. Only 5 patients (4.8%) underwent ERCP within 24 hours of admission—2 with grade III, 1 with grade II and 2 with grade I. Within 72 hours, 31 patients (29.8%) had undergone ERCP—9 with grade III, 16 with grade II and 6 with grade I. Notably, 70.8% of grade III cases were submitted to ERCP more than 72 hours after admission, with a median of 3 days of antibiotics before the procedure. There was no statistically significant association between ERCP timing and patient age, cholangitis severity, intensive/intermediate care admission or anticoagulant/antiplatelet use. However, admission on a Friday or Saturday was significantly associated with delayed ERCP (p=0.007), with 91% of these patients undergoing ERCP after 72 hours, compared to 56% for admissions on other days. Cholangitis severity correlated significantly with total hospital stay (grade I: 7 ± 3 days, grade II: 8 ± 3.8 days, grade III: 10.5 ± 9 days; p=0.001). ERCP timing was also associated with total antibiotic duration (<24h: 9 ± 2.6 days, 24–72h: 8 ± 3 days, >72h: 10 ± 4.8 days; p=0.043). The 30-day mortality rate was 4.8%, with no significant association with ERCP timing or severity grade.

Conclusion

In this real-world cohort, ERCP was frequently delayed beyond the recommended window, even in severe acute cholangitis. Weekend admission was a significant contributor to this delay. However, no association was found between ERCP timing and 30-day mortality, likely due to small sample size. These findings highlight the need for optimized access to biliary drainage, particularly during weekends, to better meet guideline recommendations.

Clinical Case Summary

Introduction: Rituximab, a monoclonal anti-CD20 antibody, is widely used for treating hematologic malignancies and autoimmune disorders due to its B-cell depleting action. While gastrointestinal side effects like diarrhea are seen in up to 15% of patients, these are typically mild and self-limiting. Severe colitis is a rare but increasingly recognized complication.
Case Description: A 76-year-old diabetic male with a history of ACS (post-PTCA in 2021) presented with 2 months history of generalized abdominal pain, watery diarrhea (6–7 episodes/day), and weight loss. He had a history of follicular lymphoma diagnosed 4 years prior, treated with 6 cycles of CHOP-R followed by rituximab maintenance (375 mg/m² every 3 months). Symptoms began after the 6th maintenance dose.Physical exam revealed mild pallor;abdomen was soft, nontender. Labs showed normocytic anemia and mild neutrophilic leukocytosis. Stool tests were negative for common pathogens, including C. difficile. The patient was planned for a Colonoscopy, which revealed ulcers over the ileocecal valve and rectal erosions. Biopsies showed mixed inflammatory infiltrates, cryptitis, crypt abscesses, and crypt rupture, consistent with severe active ileocolitis. AFB culture and GeneXpert were negative for tuberculosis.The patient was started on oral mesalamine (500 mg TID) along with Rifaximin(400mg) BD for 2 weeks, showing marked clinical improvement.
Discussion: Rituximab-induced colitis is rare and poorly understood. It may result from disruption of mucosal immunoregulation due to B-cell depletion, leading to T-cell-mediated inflammation. Histology may resemble patterns seen in GVHD or autoimmune enteropathy. Most cases resolve with supportive care and discontinuation of the drug; however, some, like this case, may require treatment in the form of 5ASA, or steroids.There is no previous data on the use of rifaximin in such cases. Differentiating drug-induced IBD from primary IBD remains a diagnostic challenge.

References

There is limited evidence in the literature establishing a definitive association between rituximab therapy and the onset of colitis. However, emerging hypotheses suggest that rituximab-induced depletion of peripheral CD19+ B cells and colonic CD20+ lymphoid aggregates may disrupt mucosal immune homeostasis, thereby contributing to structural alterations in the intestinal architecture and promoting inflammation.
The role of the gut microbiota in the pathogenesis and persistence of mucosal inflammation in inflammatory bowel disease (IBD) provides a rationale for the therapeutic use of antibiotics in selected cases. While systemic antibiotics such as ciprofloxacin and metronidazole have demonstrated clinical efficacy in IBD management, their utility may be limited in drug-induced colitis due to the potential for systemic adverse effects.
In contrast, rifaximin, a non-systemic, presents a favorable safety profile and has shown promise as a therapeutic option in both idiopathic and drug-induced enterocolitis. Its targeted antimicrobial activity within the gastrointestinal tract, combined with minimal systemic exposure, renders it an attractive alternative. However, further prospective, randomized studies are warranted to substantiate its efficacy and long-term safety in this context.