Introduction

According to the European Society of Gastrointestinal Endoscopy guidelines, non-invasive treatments, such as endoscopic treatment (ET) and extracorporeal shock wave lithotripsy (ESWL), are available for treating pancreatic head stones. However, their efficacy for pancreatic tail stones (PTS) remains unclear.

Aims & Methods

The purpose of this study was to investigate the efficacy of ET and ESWL in the management of PTS. We conducted a single-center, retrospective study of 45 painful chronic pancreatitis patients with PTS and pancreatic body stones (PBS) who underwent non-invasive treatments between January 2008 to December 2021. The primary outcome was to determine the rates of pancreatic stone removal using ET and PTS. We also focused on and evaluated the “crab claw sign” specific to the pancreatography of caudal main pancreatic duct (MPD) stones. The secondary outcome was to identify procedural factors using logistic regression analysis.

Results

PTS (n=18) group had a significantly lower complete stone removal rate than PBS (n=27) group (22.2% versus 55.6%; P=0.03). ERCP revealed crab claw signs in 60% of cases (PTS, 77.8%; PBS, 48.1%; P=0.07), of which 48.1% could advance the guide wire into the peripheral MPD (PTS, 42.9%; PBS, 53.8%; P=0.7). Multivariate analysis revealed that PTS (OR, 0.23; 95% CI, 0.06–0.88; P=0.03), stone diameter (OR, 0.23; 95% CI, 0.06–0.88; P=0.03), number of ESWL total shots (OR, 0.06; 95% CI, 0.008–0.56; P=0.01), and crab claw sign (OR, 0.07; 95% CI, 0.01–0.28; P=0.0002) were significant factors associated with failure of stone removal.

Conclusion

Our findings indicate that large PTS with crab claw signs resist ET/ESWL treatments. These findings contribute to determining whether PTS patients should initially undergo non-invasive therapy or surgical treatment.

References

Dumonceau JM, Delhaye M, Tringali A, et al. Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - updated August 2018. Endoscopy 2019;51:179-193.

Introduction

Hepatocellular carcinoma (HCC) is the most common primary malignant liver cancer globally and ranks as the third leading cause of cancer-related mortality. Treatment with immune checkpoint inhibitors (most commonly atezolizumab in combination with bevacizumab) is the most effective first-line systemic therapy for patients with advanced HCC. Since it is a new method of treatment, there is little clinical data on the use of this combination of drugs in practice (outside of prospective studies). This study aims to present the clinical outcomes of patients with HCC who underwent immunotherapy at our center over the past three years.

Aims & Methods

In this retrospective observational study, we included patients treated with the atezolizumab and bevacizumab combination between March 2020 and September 2023. Demographic information, general physical assesments, disease etiology, disease staging, liver cirrhosis status, portal hypertension and laboratory values (aminotransferases and total bilirubin) were collected. Adverse events were analyzed according to the Common Terminology Criteria (CTCAE). Descriptive statistics and survival analysis were performed using Statistical Package for the Social Sciences (SPSS) version 22.

Results

53 HCC patients received atezolizumab and bevacizumab in studied time period, 8 (15.1%) females and 45 (84.9%) males. The median age at the initiation of immunotherapy was 68 years (range 41 – 84 years). Thirteen patients (24.5%) had esophageal varices prior to immunotherapy, with three (5.6%) requiring ligation. The majority of patients had liver cirrhosis A 27 (50.9%) according to Child Pugh criteria, a minority B (9.4%), and 21 patients (39.6%) were without cirrhosis. The primary causes of the disease were alcohol (51.6%), metabolic dysfunction-associated steatotic liver disease (MASLD) (16.1%), hepatitis C virus (12.9%), hepatitis B virus (6.5%), and hemochromatosis (3.2%). Stage C HCC, according to The Barcelona Clinic Liver Cancer, World Health Organization (WHO) performance status 0, and absence of macrovascular invasion and extrahepatic spread were predominant at treatment initiation. Grade I or II adverse events occurred in almost all patients (98.1%). Severe adverse events were present in 36 patients (67.9%). Due to severe side effects, 8 (15.1%) patients discontinued treatment, 2 (3.8%) died due to treatment related complications (encephalitis and bleeding from esophageal varices). Treatment was modified in 21 (39.6%) patients due to adverse events. The estimated median survival was 15.7 months.

Conclusion

The majority of patients with unresectable HCC, treated with a combination of atezolizumab and bevacizumab immunotherapy, experienced adverse events, primarily grades I-II. The immunotherapy combination proved to be more effective in patients with viral etiology of liver cirrhosis. The estimated median survival was 15.7 months. This combination of immunotherapy has been demonstrated to be a safe and effective treatment method. Currently, there is limited data regarding the utilization of this treatment in standard clinical practice and our data aligns reasonably well with the findings of the registration study.

References

1. McGlynn KA, Petrick JL, El-Serag HB. Epidemiology of Hepatocellular Carcinoma. Hepatology. 2021 Jan;73 Suppl 1(Suppl 1):4–13.
2. Reig M, Forner A, Rimola J, Ferrer-Fàbrega J, Burrel M, Garcia-Criado Á, et al. BCLC strategy for prognosis prediction and treatment recommendation: The 2022 update. J Hepatol. 2022 Mar;76(3):681–93.
3. Finn RS, Qin S, Ikeda M, Galle PR, Ducreux M, Kim TY, et al. Atezolizumab plus Bevacizumab in Unresectable Hepatocellular Carcinoma. N Engl J Med. 2020 May 14;382(20):1894–905.
4. Lee YC, Huang WT, Lee MY, Tsao CJ, Feng YH. Bevacizumab and Atezolizumab for Unresectable Hepatocellular Carcinoma: Real-world Data in Taiwan-Tainan Medical Oncology Group H01 Trial. In Vivo. 2023;37(1):454–60.
5. Himmelsbach V, Pinter M, Scheiner B, Venerito M, Sinner F, Zimpel C, et al. Efficacy and Safety of Atezolizumab and Bevacizumab in the Real-World Treatment of Advanced Hepatocellular Carcinoma: Experience from Four Tertiary Centers. Cancers (Basel). 2022 Mar 28;14(7):1722.
6. de Castro T, Jochheim LS, Bathon M, Welland S, Scheiner B, Shmanko K, et al. Atezolizumab and bevacizumab in patients with advanced hepatocellular carcinoma with impaired liver function and prior systemic therapy: a real-world experience. Ther Adv Med Oncol. 2022;14:17588359221080298.

Introduction

H. pylori infection can remain after several eradication attempts. The objective of this study was to evaluate the effectiveness of the sixth-line rescue treatment in Europe.

Aims & Methods

Systematic and prospective registry on the clinical management of H. pylori infection. All cases with six eradication attempts registered in AEG-REDCap up to December 2022 were evaluated. The modified intention-to-treat (mITT) and per-protocol (PP) effectiveness was analysed.

Results

Overall, 81 patients were included, mainly from Spain (44% of cases), Italy (26%) and the United Kingdom (17%). The mean age was 52 years, with 52% women and 1.2% of patients allergic to penicillin. Culture was performed in 26 cases (32%), of which: 13 (50%) had bacterial antibiotic resistance to clarithromycin, 12 (46%) to nitroimidazole, and 8 (31%) to quinolones. In addition, 8 (35%) patients had dual resistance (both to clarithromycin and metronidazole) and 7 (27%) triple resistance (also to levofloxacin). Twenty-two different therapeutic combinations were used, most of them prescribed for 14 days (57%) and with low doses (39%) of PPIs. The most frequent treatments were: quadruple bismuth-tetracycline-metronidazole prescribed as three-in-one single-capsule (17%), triple amoxicillin-rifabutin (15%), quadruple bismuth-furazolidone-amoxicillin (11%), triple amoxicillin-levofloxacin (7.4%), and classical quadruple bismuth-tetracycline-metronidazole (6.2%). The highest eradication rates (mITT) were achieved with the single-capsule (77%) and with the quadruple therapy with bismuth-furazolidone-amoxicillin (67%). Overall effectiveness was 53%, both by mITT and PP analyses. Additional information on effectiveness, tolerability, compliance, and prior therapies is shown in the table.

Conclusion

Sixth-line eradication treatments in Europe obtain suboptimal eradication rates. The only therapies that reach acceptable outcomes are the bismuth quadruple therapies with either tetracycline-metronidazole (single-capsule) or with furazolidone-amoxicillin.

Disclosure

Olga P. Nyssen received research funding from Mayoly and Allergan.
Javier P. Gisbert served as speaker, consultant, and advisory member for or received research funding from Mayoly, Allergan, Diasorin, Gebro Pharma, and Richen.

Introduction

Acute pancreatitis (AP) is a common cause of acute hospital admissions, with the potential for severe acute complications, progression to chronic pancreatitis and recurrent episodes. A first presentation leads to investigations to identify a cause, including serum blood tests and transabdominal ultrasound. Following these investigations, a significant minority of patients have no clear cause for pancreatitis. Endoscopic ultrasonography (EUS) can identify aetiologies of AP, and direct intervention to reduce recurrence. The goal of this study was to determine the diagnostic yield of EUS and the impact of subsequent biliary intervention on recurrence of AP.

Aims & Methods

This was a retrospective service evaluation of EUS referrals to a regional referral centre in the UK from January 2015 to December 2019. Demographics, symptoms, liver blood tests, non-invasive imaging, EUS records and outcomes were reviewed. A EUS was labelled as diagnostic if findings were identified which explained the cause for pancreatitis that had not been explained with other investigations. Symptom resolution was defined as no further episodes of acute pancreatitis or abdominal pain requiring investigation, imaging, or presentation to secondary care during the follow-up period. Statistical significance for the difference between proportions was calculated using chi-squared tests.­­­­­­­­­­

Results

Ninety-seven patients were included in the study. The median age of the cohort was 58 (range 18-88) years. 55 (57%) patients were male. 22/97 (23%) patients had previously had a cholecystectomy. 41/97 (42%) had abnormal liver blood tests at the time of referral. Three patients had no non-invasive imaging. 27/97 (28%) had one of either transabdominal ultrasound, MRCP or CT, 63/97 (65%) had two tests and 4/97 (4%) had all three. 5 (5%) patients previously had a non-diagnostic EUS.
72/97 (74%) EUS were diagnostic. Findings included gallstones (n=15), gallbladder microlithiasis/sludge (n=51), bile duct stones (n=13), bile duct microlithiasis/sludge (n=11), chronic pancreatitis (n=7) and a pancreatic mass (n=1) which was later diagnosed as a pancreatic adenocarcinoma.
65 patients had a biliary aetiology for their pancreatitis which was amenable to treatment. Of these, 12 had subsequent ERCP, 7 had ERCP and cholecystectomy, 33 had a cholecystectomy and 13 were treated conservatively. Recurrent pancreatitis occurred in 12/52 (23%) patients who had treatment for a biliary aetiology of their pancreatitis compared with 8/13 (75%; p<0.01) of patients who were managed conservatively despite a biliary aetiology for pancreatitis, 8/32 (25%; p=0.84) of patients with a diagnostic EUS with a finding not amenable to treatment or a non-diagnostic EUS experienced further episodes. One patient died from complications related to acute pancreatitis and was not included in this analysis. Median duration of follow-up was 51 months (range 32-80 months).

Conclusion

In our cohort of patients referred for EUS for unexplained acute pancreatitis, EUS had a high diagnostic yield. A lower proportion of patients had a biliary aetiology for their pancreatitis that was amenable to intervention with either ERCP, cholecystectomy or both procedures; these patients experienced fewer episodes of recurrent acute pancreatitis than those managed conservatively. This supports the use of EUS in patients with acute pancreatitis with no cause identified with non-invasive imaging.

Clinical Case Summary

Endoscopic full-thickness resection (eFTR) is an emerging technique that enables effective and safe management of complex colorectal (CR) lesions. In recent years, eFTR has been described as an alternative to surgery in selected patients, namely for scars aiming to exclude residual tumors after non-curative endoscopic resection. We present a case of eFTR due to imaging suspicion of intraparietal colorectal recurrence without endoscopic findings.
A 41-year-old woman with Lynch syndrome (dMLH1) and a history of rectal adenocarcinoma underwent anterior resection of the rectum and adjuvant chemoradiotherapy at the age of 20. Afterwards endoscopic surveillance was initiated. At the age of 39, she presented with a suspicious lesion (Paris 0-Is+IIa, NICE 2, JNET2B), 16mm, in the hepatic angle, and underwent enbloc endoscopic mucosal resection. Histopathological analysis revealed a low-grade invasive colorectal carcinoma (CRC) with deep invasion of the submucosa (vertical R1). After a multidisciplinary meeting, complementary surgery was proposed but the patient refused, maintaining close surveillance. Two subsequent endoscopic revisions and two computed tomography (CT) scans showed no signs of macro or microscopic recurrence, even after extensive biopsies of the colonic scar. However, a CT scan 20months post-resection showed a 2cm parietal thickening in the hepatic angle. Suspecting parietal tumor recurrence without superficial endoscopic findings, a transmural endoscopic resection using FTRD® of the scar was performed. Histology revealed no tumor recurrence.
Transmural evaluation of the scar after noncurative endoscopic resection of T1 CRC, whether for excluding residual tumor or during surveillance to exclude recurrence, represents a promising indication for eFTR. This technique has demonstrated to be a safe and effective therapeutic alternative for this new indication, avoiding surgery and its associated morbidity and mortality.

References

Aslanian HR, Sethi A, Bhutani MS, Goodman AJ, Krishnan K, Lichtenstein DR, et al. ASGE guideline for endoscopic full-thickness resection and submucosal tunnel endoscopic resection. VideoGIE 2019;4:343–50. https://doi.org/10.1016/j.vgie.2019.03.010.
Gijsbers K, Laclé M, Elias SG, Backes Y, Bosman J, van Berkel A. Full-Thickness Scar Resection After R1 / Rx Excised T1 Colorectal Cancers as an Alternative to Completion Surgery : Official journal of the American College of Gastroenterology | ACG. Am J Gastroenterol 2022;117:647–53. https://doi.org/10.14309/ajg.0000000000001621.
Pimentel-Nunes P, Libânio D, Bastiaansen BAJ, Bhandari P, Bisschops R, Bourke MJ, et al. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy 2022;54:591–622. https://doi.org/10.1055/a-1811-7025.

Introduction

New biologics such as vedolizumab (VDZ) and ustekinumab (UST) have expanded the therapeutic armamentarium for inflammatory bowel diseases (IBD) over the past decade. Head-to-head trials comparing safety to tumor necrosis factor alpha inhibitors (anti-TNF) are limited. Data on safety of biologic sequencing remains scarce.

Aims & Methods

Aim: To assess the impact of different biologics and previous treatments on the incidence of severe adverse events (SAE) in a real-world tertiary IBD patient cohort.
Methods: A retrospective monocentric study was performed at the Ghent University Hospital. Patients starting anti-TNF, VDZ or UST from January 2018 to June 2021 with follow-up until December 2021 were included. SAE were defined as intestinal resection (IR), IBD-inflammation related hospitalization (IBD-hosp), IBD-treatment related hospitalization (e.g. infections) (treat-hosp), malignancy and death. Cox regression analysis was used to explore risk factors (RF) of SAE.

Results

In total 267 patients were included: 84 on VDZ, 69 UST, 60 infliximab (IFX) and 54 adalimumab (ADM). At baseline a significant difference was found between biologic groups for age (younger in IFX and ADM - P=0.001), IBD type (Crohn’s disease (CD): VDZ 51.2%, UST 73.9%, IFX 70%, ADM 77.8% - P=0.003), CRP (in mg/L, med, IQR - VDZ: 5[1.6-12.4], UST: 8.5[2.8-19.3], IFX: 13 [1.87-31.8], ADM:3.2[1-8.1] - P<0.001) and calprotectin (in µg/g, med, IQR) (VDZ: 579 [175- 1801], UST: 707 [244-2889], IFX: 652 [65-2449], ADM 200 [43.7-789] - P=0.021)). Perianal CD rate was higher in anti-TNF and UST patients (P=0.003) and prior disease duration differed significantly (VDZ: 9years, UST10y, IFX 2y,ADM 3.5y - P<0.001)). Concomitant immunomodulator (IMM) use was higher in the IFX group (81.7% vs 25% for all other groups P<0.001)) and corticosteroid (CS) use differed among treatment groups (VDZ 78.6%, UST 68.1%, IFX 70%, ADM 55.6% (P=0.041)). Number of prior biologics was higher in the UST group (P<0.001).
No significant difference in SAE rate could be found between different biologics (UST 37.7%, IFX 33.3%, VDZ 23.8%, ADM 22.2% - P=0.148). Cox regression revealed age ≥60years (aHR 2.00, 95%CI 1.11-3.60, P=0.020) and higher number of previous biologics (aHR 1.29, 95%CI 1.03-1.60, P=0.024) as independent RF for SAE. Considering SAEs types, IR rate was not significantly different between biologic groups (VDZ 4.8%, UST 15.9%, IFX 8.3%, ADM 5.6% - P=0.096). Cox regression revealed previous IMM use as an independent RF for IR (aHR 4.26, 95%CI 1.62-11.19, P=0.003). No significant difference was found between biologics considering IBD-hosp (VDZ 15.5%, UST 30.4%, IFX 21.7%, ADM 14.8% – P=0.087). Higher number of previous biologics was an independent RF for IBD-hosp (aHR 1.32, 95%CI 1.02-1.71, P=0.036). Treat-hosp rate was not significantly different between biologic groups (VDZ 7.1%, UST 10.1%, IFX 6.7%, ADM 5.6% – P=0.811). Age ≥60years was found to be an independent RF of treat-hosp (aHR 4.93, 95%CI 1.91-12.76, P=0.001). Six patients developed malignancy (3 VDZ: colorectal carcinoma, melanoma, low grade appendix neoplasia; 2 IFX: cervix CIN3, gastric adenocarcinoma; 1 ADM: basal cell carcinoma). One patient died due to progressive melanoma while on VDZ.

Conclusion

In this tertiary real-world IBD patient cohort, no influence of type of biologic on the SAE rate could be found. Elderly age (≥60 years) and higher number of previous biologics were an independent RF for SAEs.

Introduction

The urea breath test (UBT) is the clinic's most popular and accurate non-invasive diagnostic method for H. pylori infection. Yet, it is time-consuming and unavailable to some individuals. The oral rapid urease test (RUT) is an emerging non-invasive convenience method but lacks clinical data support.

Aims & Methods

A double-center, double-blind, methodological comparative design experiment is invited to evaluate the consistency of the oral RUT with UBT. 247 participants were enrolled. Their Dental plaque and tongue coating samples were collected, blind and tested with RUT.

Results

The significant association between the RUT and UBT was analyzed.A total of 247 participants were included in the study. The oral RUT showed a high level of agreement with the UBT. The sensitivity of the test reagent was 98.63% (95% CI: 92.64%, 99.76%), and the specificity was 96.34% (95% CI: 92.25%, 98.31%). The overall conformity rate was 97.05% (95% CI: 94.03%, 98.56%). The positive predictive value was 92.31%, and the negative predictive value was 99.37%. The positive likelihood ratio was 26.96, and the negative likelihood ratio was 0.01. The Kappa value was 0.97.

Conclusion

The efficacy of oral RUT for Helicobacter pylori infection diagnosis is extremely consistent with the UBT.