Introduction

Biodegradable pancreaticobiliary stents provide an alternative to conventional stents and avoid the need for a repeat procedure for endoscopic removal. While use is not currently widespread in the United Kingdom, accepted indications for insertion include bile leaks, prophylaxis of post-ERCP pancreatitis and as a bridge to cholecystectomy after bile duct clearance. Evidence from small studies suggest biodegradable stents are safe and cost effective, however there are few prospective studies to guide best practice. Complications of biodegradable stents are also not well understood with limited, if any, data describing issues specific to these types of stent. In our hospital trust, biodegradable stents have been in use since 2019 and this study aims to describe trends in use including complications and provide a comprehensive summary experience to date.

Aims & Methods

The electronic record of all patients in two hospitals within Manchester foundation trust who underwent insertion of a biodegradable pancreaticobiliary stent were reviewed. The study period was between March 2019 and April 2023. Patient demographics, type of stent, indication for stent insertion, readmissions and repeat ERCP data was collected on review of each patient’s record.

Results

During the study period 66 Biodegradable stents were inserted in 63 patients of which 48 were pancreatic and 18 biliary. All pancreatic stents were inserted for post-ERCP pancreatitis prophylaxis, whilst 5 biliary stents were performed for bile leaks and 13 for biliary drainage post-ERCP. A total of 9 patients were readmitted within 6 months for a pancreaticobiliary related complications including cholangitis (n=3), cholecystitis (n=2), post-ERCP pancreatitis (n=2), biliary obstruction (n=1) and persistent bile leak (n=1). In total, 10 patients underwent repat ERCP within 6 months. In one patient, the biodegradable stent was noted at ERCP to be in situ ERCP 5 months after insertion. Over 94% (n=17) of all biliary stents were performed in the first year of study, although the majority of these were inserted in 1 of the 2 study centres.

Conclusion

To our knowledge this is the largest series of patients undergoing biodegradable stent insertion in the United Kingdom. In this study, the most common indication for the insertion of a biodegradable stent was post-ERCP pancreatitis prophylaxis. As the study period progressed pancreatic stents became by far the most commonly inserted stent. In fact, only 1 biliary stent was placed in the final 3 years of the study period, demonstrating a trend towards the use of pancreatic biodegradable stents versus biliary stents. This may represent differences in clinical practice, services provided over time (e.g Spyglass or ‘hot’ cholecystectomies) or simply endoscopist preference. The study suggests that biodegradable stents are safe and effective with only 10 patients undergoing a further ERCP in 6 months. Therefore, a significant proportion of patients were able to avoid a second procedure thus providing a benefit in both risk and cost.

Disclosure

None

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

Acute upper gastrointestinal (UGI) bleeding is a common medical emergency among the elderly. There is limited data on the management and outcomes of non-variceal UGI bleeding in the elderly in India.

Aims & Methods

We aimed to study clinical presentation, endoscopic findings, and outcomes in elderly patients with acute non-variceal UGI bleeding. All elderly patients (≥ 60 years of age) who presented with acute UGI bleed and were admitted for the same from 2021 to 2022 were retrospectively analysed. Baseline characteristics, blood transfusions before and after endoscopy, endoscopic diagnosis and therapy, AIMS65 score, complete Rockall score, and outcomes such as in-hospital re-bleeding and mortality were recorded.

Results

Of the 399 patients who had acute non-variceal UGI bleed, 309 patients aged <60 years were excluded. Of the 90 patients studied, the mean age of presentation was 69.8 ± 7.35 years, with 81.1% males. The most common presentation was melena (30%). Forty-one (45.5%) patients had a history of antiplatelet and anticoagulant use. The most common endoscopic finding was gastric ulcer (54.4%), followed by duodenal ulcer (22.2%), gastroesophageal junction ulcer (7.7%), Mallory-Weiss tear (6.6%), duodenal diverticular bleed (2.2%). The majority of ulcers were Forrest III (43.3%), followed by Forrest IIa (23.3%) and IIc (18.3%). Around 65% of patients with non-variceal UGI bleeds did not require endotherapy. Dual endotherapy was done in 25.5.5% of patients. Triple endotherapy was done in two patients. AIMS65 score was 1 in 50% of patients and 2 in 24.5% of patients. The majority (81.1%) of patients had a complete Rockall score of 3-7, indicating a moderate risk of re-bleeding and mortality. All the 90 patients were discharged without any mortality.

Conclusion

Our study showed that gastric ulcer was the most common cause of acute non-variceal UGI bleeding in the elderly, and melena was the most common presentation. Early endoscopic therapy may reduce blood transfusion requirements, in-hospital re-bleeding, and mortality.

Introduction

Biliary pain is a common cause of morbidity both before and after cholecystectomy. Endoscopic ultrasonography (EUS) is sensitive for the diagnosis of biliary pathology and can identify disease that is occult on other imaging modalities. The aim of this study is to determine the diagnostic yield of EUS when performed for biliary pain.

Aims & Methods

This was a retrospective service evaluation of EUS referrals to a regional referral centre in the UK. All local patients who were referred for EUS for suspected biliary pain between January 2015 to December 2019 were included. Demographics, symptoms, liver function tests (LFTs), non-invasive imaging, EUS reports and clinical outcomes were reviewed. Biliary dilatation was defined as greater than 7mm pre-cholecystectomy and greater than 10 mm post-cholecystectomy. A EUS was considered as diagnostic for a cause of biliary pain if findings were identified which explained symptoms. Symptom resolution was defined as no further investigation, review or imaging performed for biliary symptoms in secondary care during the follow-up period. Statistical significance for proportions was calculated using chi-squared tests.

Results

565 patients were included in the study. The median age of the cohort was 55 (range 17-89) years. 161 (28%) patients were male. 241 (43%) patients had previously had a cholecystectomy. The study participants had been extensively investigated with previous imaging which was non-diagnostic; in total the patients had 500 trans-abdominal ultrasound scans, 316 CT scans, 315 MRCPs and 77 previous EUS.
334 (59%) EUS were considered diagnostic. Patients who had previously had a cholecystectomy were less likely to have a diagnostic EUS compared to those who had a gallbladder ((99/241 (41%) vs 235/324 (73%); p<0.01). The diagnostic yield of EUS was higher in patients with abnormal LFTs or a dilated biliary tree and in those with both abnormal LFTs and biliary tree dilatation (table 1).

Positive findings included gallstones (n=92), gallbladder microlithiasis/sludge (n=181), bile duct stones (n=85), bile duct microlithiasis/sludge (n=108), chronic pancreatitis (n=21) and mass lesions (n=4) which were later diagnosed as metastatic renal cell cancer, pancreatic cancer and two ampullary adenomas.
311 patients had a diagnostic EUS with a biliary aetiology for their pain which was amenable to treatment. Symptom resolution occurred in 85/136 (63%) who had ERCP, 21/24 (83%) who had both cholecystectomy and ERCP, 63/94 (67%) who had a cholecystectomy and in 19/57 (33%) who were managed conservatively. Patients with a diagnostic EUS were more likely to have resolution of their symptoms compared to those with no cause identified ((207/334 (62%) vs 81/231 (35%); p<0.05). Median duration of follow-up was 54 months (range 32-81 months).

Conclusion

In our cohort of patients with biliary pain who have been previously investigated, EUS is associated with a high diagnostic yield across all groups, although this yield increases in patients with abnormal LFTs, a dilated biliary tree, or both. A diagnostic EUS leads to biliary intervention in a high proportion of patients, and patients who have EUS-guided intervention appear have a greater chance of becoming symptom free than those without a diagnostic EUS. This supports investigation of patients with suspected biliary pain with EUS, regardless of whether their liver blood tests are abnormal or their bile ducts are dilated.

Introduction

Inflammatory Bowel Diseases (IBD) patients are associated to a higher risk of developing colonic dysplasia and colorectal cancer due to long-standing colonic inflammation and immunosuppressant therapies. They seem to have also a higher risk of developing extra-intestinal malignancies, such as cholangiocarcinoma, skin cancer, and others. Different studies have been conducted to assess whether a correlation exists between IBD, medical treatments and cancers, but the results are controversial.

Aims & Methods

Our study aimed to evaluate the risk factors of malignancies in our IBD patients, particularly considering the medication history.
In this single-center retrospective study, IBD patients with a history of at least one malignancy post-IBD diagnosis followed at the Gastroenterology Unit of Azienda Ospedale Università Padova were enrolled (cases). Demographics and clinical data, including medication information, were collected before and at the time of malignancy diagnosis. A group of IBD patients, matched by sex and age, without a malignancy history were also included (controls), considering the medications taken before and at the time of the last visit for comparison.

Results

Among 2213 IBD patients followed at our center (1212 males, 1040 CD, and 1173 UC), 153 cases (80 UC and 73 CD, 46.4% males, mean age at diagnosis: 38.4±14.7) and 50 sex and matched controls were included (30 UC and 20 CD, 52% males, mean age at diagnosis: 38.9±0.8). Twelve patients had two malignancies, and 2 had three. For the scope of our study, we considered only the first tumor. Results are shown in the Table 1. The mean time from IBD diagnosis to the first tumor was 15 years (SD 10.5). Considering malignancies, the most frequent in our population were breast cancer (27/1001 females, 2.7%), colorectal cancer (23/2213, 1%), melanoma (24/2213, 1.1%), and non-melanoma skin cancer (15/2213, 0.7%). Patients with colon cancer were younger at the time of IBD diagnosis (31.0±15.8 vs. 38.9±0.8), while patients with prostate and urinary cancer (11/2213, 0.5%) were older compared to controls (49.6±13.7 vs. 38.9±0.8). A lower percentage of patients with colon (13%), breast (4%), and prostate cancers (9.1%) had taken biological therapy before cancer occurrence, as compared to controls (44%, p<0.01). Finally, we observed a significantly higher number of melanoma and breast cancer patients taking azathioprine (AZA) at the time of cancer diagnosis for more than 4 years. No difference in terms of duration of AZA and biological therapies before cancer diagnosis was observed.

Table 1: Type and frequency of Malignancies and characteristics of the patients

Conclusion

Our study found that biological therapy was not associated to malignancies, while azathioprine use was associated with breast and melanoma cancers. A younger age at diagnosis was associated with colon cancer, while an older age with prostate and urinary cancers.