Introduction

Gastroscopy is the key tool in the diagnosis of upper gastrointestinal tract (GIT) cancers. Cases of cancer missed by upper endoscopy represent the diagnostic limitation of this method. Proportion of this cases is estimated around 10 % according to the literature. A negative gastroscopy within 3 years prior to cancer diagnosis is considered failing.

Aims & Methods

Aim: to determine the proportion of upper GIT cancers missed by upper endoscopy in the Czech Republic.
Methods: Analysis from the National Registry of Reimbursed Health Services (2010-2021) and National Oncological Registry (2010-2020) was performed. Newly diagnosed cancer cases were identified: oesophagus (C15), stomach (C16) and duodenum (C170). Gastroscopy performed at an interval of 0-6 months before was considered diagnostic. On the other hand, cases with gastroscopy performed between 7 and 36 months were considered a failure of endoscopic diagnosis.

Results

16 897 new cases of upper GIT neoplasia were diagnosed between years 2013 and 2020. Cases without complete data covering 3-year period (410 cases) and cases without any gastroscopy 3 years before (1,786 cases) were excluded, leaving 14,701 cases available for further analysis. Gastroscopy in the interval 0-6 months only was performed in 12,811 patients. Gastroscopy both in 0-6 months interval and 7-36 months interval was performed in 1,581 patients (10.8 %); gastroscopy only in the interval of 7-36 months was performed in 309 patients (2.1 %): thus, in total 1,890 cases of suspected diagnostic failure were identified (12.9 %). This number does not decline with time interannually. The groups of missed and correctly diagnosed cases did not differ in age (p = 0.965; Mann-Whitney test); incidence of missed cancers was higher in woman compared to men (15 % vs. 12 %, p<0.001; Fisher's exact test) and the proportion of missed cases decreases with higher cancer stages (stage 1: 21 %, stage 2: 13 %, stage 3: 10 %, stage 4: 9 %).

Conclusion

Gastroscopy in the Czech Republic is suspected to miss up to 12.9 % of upper GIT cancers and this number has been stable over past 8 years, with failure being slightly more common in women. From this perspective, the potential of gastroscopy in the Czech Republic is comparable to current data from other regions and represents a room for quality improvement.

Introduction

There are several preoperative localization methods for laparoscopic colorectal surgery. ICG (indocyanine green) injection has recently been in the limelight for preoperative localization. However, although the incidence is low, ICG injections may cause complications due to allergic reactions. In this study, we tried to check the feasibility and safety of autologous blood tattooing as an alternative to ICG.

Aims & Methods

From august in 2017 to July 2023, a total of 42 patients were preoperative endoscopic localization. Through preoperative endoscopy, 33 patients underwent autologous blood tattooing and 9 patients underwent ICG tattooing. The surgeon checked visibility and other complication such as abscess or spillage at the start of surgery. The characteristics of patients, outcomes, and complications were collected retrospectively.

Results

Patients characteristics showed no significant difference between the two groups. As for the location of localization, sigmoid colon was the most common in both groups. The two groups each had one imprecise localization. In autologous blood tattooing patient, the omentum interfered with detection, and in ICG tattooing patient, blurring was severe. In addition, in patients with autologous blood tattooing, detection was not possible in 2 patients due to adhesion and technical failure. In the case of complications, there was only one spillage in the ICG group, which resulted in blurring.

Conclusion

Preoperative autologous blood tattooing is a simple and useful technique because it has high visibility, and no complication. This method has the advantage that it does not require additional agents or facilities and can be performed quickly and accurately through the patient's blood. However, unlike ICG tatooing, there is a disadvantage that it is difficult to secure a field of view when there is an obstruction structure such as an omentum. In the future, further study of large size will be needed.

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

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.

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

Emergency surgery (ES) is associated with higher morbidity and mortality for acute left colonic malignant obstruction. Since the first application of self-expandable metallic stent (SEMS), the technique has been popularly applied as “bridge to surgery (BTS)”. The short-term clinical outcomes and long-term oncologic prognosis remain controversial.

Aims & Methods

This retrospective study aimed to compare the performance for managing acute left colonic malignant obstruction by ES or BTS. The medical records were collected from May 2015 to December 2019 in two tertiary hospitals in Eastern China. Patients were followed up after surgery every 6 months for 3 years and once a year afterwards. Clinical success was defined as resumption of intestinal function for 30 days without morbidity or mortality after surgical procedure. All demographics, intervention procedures and follow-up were analyzed for short-term and long-term outcomes. Risk factors for long-term survival were discussed as well.

Results

A total of 136 patients were eligible for the study, 67 in BTS group and 69 in ES group. No significant differences concerning demographics were found, including age, sex, body-mass index (BMI), symptoms, coexisting disorders, laboratory tests, preoperative radiotherapy or chemotherapy, previous history of abdominal surgery, cancer location, obstructive degree and TNM stage. Technical success of SEMS insertion was achieved in 64 patients (95.5%). The interval from SEMS placement to elective surgery was 16 days. Minor perforation was detected on 4 patients during the elective surgery, while no symptomatic complaint was recorded.
BTS group showed better short-term performance, including less intraoperative decompressive intervention (85.1% vs. 69.6%, p=0.045), more complete decompression (64.2% vs. 27.5%, p＜0.001), more primary anastomosis (65.7% vs. 17.4%, p＜0.001), less temporary and permanent stoma (34.3% vs. 82.6%, 13.4% vs. 58.7%, both p＜0.001), less intensive care unit requirement (10.4% vs. 27.5%, p=0.011), less intraoperative complications (3.0% vs. 13.0%, p=0.031) and reduced 30-day mortality (0 vs. 8.7%, p=0.028). Longer hospitalization was observed in the BTS group (21.7±13.3 days vs. 14.9±7.6 days, p＜0.001). Postoperative hospitalization and total cost were comparable between the two groups. No significant difference was observed about clinical success (73.1% vs. 63.8%, p=0.240), overall mortality (53.7% vs. 64.4%, p=0.247) or long-term survival (52.0 months vs. 35.0 months, p=0.121). TNM stage Ⅳ, permanent stoma and postoperative complication were the independent risk factors for long-term survival.

Table.1 Operation related characteristics

Conclusion

SEMS served as a safe and effective bridge to elective surgery for acute left colonic malignant obstruction, without adverse effect on long-term survival. It significantly improved short-term outcomes by reducing perioperative complication, 30-day mortality and stoma. More prospective studies are necessary for further evaluating the clinical values of SEMS, and weighing its benefits against potential complications.

References

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