Introduction

Mucinous cysts of the pancreas are known precursors of pancreatic ductal adenocarcinoma. International guidelines for management and surveillance of pancreatic cysts advise surgical resection of high-risk lesions - mucinous cystic neoplasms (MCNs) and main duct intraductal papillary neoplasms (IPMNs), especially in those with worrisome clinicopathological stigmata. For low-risk cysts, lifelong radiographic surveillance is the standard approach, which can be psychologically distressing for patients and burdensome for healthcare systems. Endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA) of high-risk cystic lesions of the pancreas is increasingly being used as a minimally invasive alternative in patients who are unfit for or who decline surgery (1). We assessed the safety and efficacy of EUS-guided RFA in the management of low-risk cystic lesions of the pancreas.

Aims & Methods

68 patients (29M, 39F; mean age 63, range 33-82 years) with low-risk mucinous cystic neoplasms of the pancreas (branch-duct IPMN/mucinous cystadenomas, 0.7-4cm in size) were recruited for treatment by EUS-RFA. The primary endpoint was change in size of the pancreatic cyst on cross-sectional imaging (MRI) at one year after treatment (efficacy). Secondary endpoints included progression following treatment, procedure related morbidity and local complication rate (safety).

Results

68 patients were recruited of whom 55 completed RFA ablation of their cyst. Anatomical concerns (i.e., blood vessel, main duct proximity) precluded RFA in 12 patients. 18/55 patients (33%) underwent a second ablation. Follow up imaging data were available for 46 (84%) patients and showed a <20% reduction in cyst size in 18 patients, 20-49% in 4 patients, 50-79% in 5 and 80-100% size reduction in 18 patients. For one patient, doubling in cyst size was recorded at the 12-month follow-up. Excluding one case of scope-induced small bowel perforation (Clavien-Dindo; ClvD grade 3), other adverse events were mild (ClvD 0-2) and expected (transient abdominal pain, bloating, sore throat, nausea/vomiting). One patient experienced a self-limiting, post procedure grand mal seizure on a background of epilepsy.

Conclusion

​EUS-RFA was well tolerated in most cases. Our data indicate that the procedure is relatively safe. The response ranged from a <20% reduction in size to complete cyst resolution.

References

1. Papaefthymiou A, Johnson GJ, Maida M, Gkolfakis P, Ramai D, Facciorusso A, Arvanitakis M, Ney A, Fusai GK, Saftoiu A, Tabacelia D, Phillpotts S, Chapman MH, Webster GJ, Pereira SP. Performance and safety of EUS-ablation techniques for pancreatic cystic lesions: a systematic review and meta-analysis. Cancers 2023 [in press].

Disclosure

No conflict of interest

Introduction

Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) can demonstrate microvascularization of the tumors. However, most images acquired from CEH-EUS are interpreted subjectively without quantification by time-intensity curves (TICs) analysis.

Aims & Methods

In this study, we used handcrafted software to quantify CEH-EUS images for objective interpretation of tumor microvascularization to make differential diagnosis of pancreatic tumors feasible.
We analyzed the videos of CEH-EUS for pancreatic tumors from the patients in National Taiwan University Hospital and Far Eastern Memorial Hospital. The convex-type echoendoscope (GF-UCT260; Olympus, Tokyo, Japan) equipped with ultrasound (US) systems (EU-ME2) was used for the procedures. The second generation of US contrast agent with Sonazoid (GE Healthcare, Milwaukee,Wisc), which contains perfluorobutane microbubbles with a median diameter of 2–3 μm, was administered bolus and intravenously with a dosage of 0.015 ml encapsulated gas per kilogram body weight. The videos were recorded in AVI formats with 30 frames/second.
The algorithm for getting TICs includes the following steps:
(1) Circling the region of interest(ROI) in the B-mode
(2) Performing speckle tracking of the ROI in the B-mode
(3) Simultaneously obtaining the intensity of ROI (the mean pixel values in the ROI) in the corresponding contrast-enhanced harmonic image
(4) Outputting TICs after subtracting the baseline intensity (defined as mean TIC in the first 10 s for eliminating the different baseline intensities caused by other settings).
(5) Outputting histogram of pixel values and excel file containing all pixel values from the frame with the highest mean pixel value automatically.
(6) Calculating the standard variance of (5) to represent the heterogeneity inside the ROI.
The speckling tracking composes of searching and matching processes. We used full search for the searching process and normalization cross-correlation for the matching process. By using the hardware of CPU with Intel i7-8750H and GPU with Nvidia GTX 1050 Ti, the computation time was 0.7 ms/frame.

Results

The detailed results were shown in Table 1. We collected 10 and 7 videos of CEH-EUS for pancreatic tumors from NTUH and FEMH respectively in this study. Among them, 9 were diagnosed of pancreatic ductal adenocarcinoma (PDAC), 6 were pancreatic neuroendocrine tumors (PNET), and 2 were autoimmune pancreatitis (AIP). The TICs were obtained through our proposed model. Briefly, there were no significant differences in times to peak, the mean peak intensity, the in-slope tangent and standard deviation of pixel value in ROI (from the frame with the highest mean pixel value) among PDAC, PNET, and AIP. However, there was significant difference in the mean peak intensities of PDAC and non-PDAC (37.88 vs 63.12, p=.031).

Table 1.The results from three kinds of pancreatic tumors based on the proposed model

	PDAC	PNET	AIP	Non-PDAC(NET & AIP)	P value(PDAC vs PNET vs AIP)	P value (PDAC vs non-PDAC)
Number	9	6	2	8
Times to peak(SD), seconds	27.50(7.98)	26.76(8.56)	21.5(5.94)	25.45(7.65)	0.632	0.598
The mean peak intensity(SD), dB	37.88(18.58)	66.10(28.91)	54.2(3.96)	63.12(25.09)	0.087	0.031
In slope(SD)	2.90(2.34)	5.07(3.87)	5.34(2.41)	5.14(3.40)	0.331	0.131
SD of pixel value in ROI (the highest mean pixel value)(SD)	34.77(9.14)	35.47(10.44)	33.94(0.08)	35.09(8.86)	0.977	0.942

Conclusion

In this study, there were no significant differences in times to peak, the mean peak intensity, and SD of pixel value in ROI (from the frame with the highest mean pixel value) among PDAC, PNET, and AIP, however there was significant difference in the mean peak intensity between PDAC and non-PDAC group. A study with larger test number is needed in the future for further application.

Disclosure

We have no conflicts of interest to disclose.

Introduction

Stent placement by endoscopic retrograde cholangiopancreatography (ERCP) is one of the preferred methods for biliary drainage in unresectable malignant biliary obstruction. Nevertheless, clinical success of palliative drainage is not easy to predict, especially at the time of ERCP.

Aims & Methods

We conducted a multicentre retrospective cohort study in 3 centres in Portugal, involving patients with unresectable malignant biliary obstruction (UMBO) submitted to palliative ERCP-guided biliary stenting between 2015 and 2022. This study aimed to evaluate clinical success of biliary drainage in our population, as well as to evaluate the performance of two recently developed and internally validated risk scores for predicting successful biliary drainage after ERCP-guided endobiliary stenting in UMBO, created by the group of Pausawasdi N. et al. This group developed a first score for predicting early clinical success of biliary drainage (decrease ≥50% in total bilirubin (TB) levels within 2 weeks after stenting), using as variables the presence/absence of extrahepatic biliary obstruction, peritoneal carcinomatosis, the type of biliary stent (plastic or metallic) and pre-endoscopic alkaline phosphatase level. The second score was developed to predict complete clinical success of biliary drainage (normalization of TB levels within 6 weeks after stenting) including pre-endoscopic TB levels, presence/absence of extrahepatic biliary obstruction and type of stent as variables. We included 217 patients for this study. However, due to the limitations of a retrospective analysis, we could not evaluate the performance of these scores for all the patients of our cohort. Statistical analysis was performed using SPSS v.29.

Results

In our cohort, a decrease in total bilirubin (TB) levels ≥50% within 2 weeks after biliary stenting was reached in 81.9%(N=113) of the patients of a subpopulation of 138 patients in which these TB levels were available. TB normalization in 6 weeks after stenting occurred in 55%(N=72) of the cases from a subpopulation of 131 patients in which this TB level was measured. In our population, the predictive scores for early and complete clinical success had an AUROC of 0.597 (95% CI, 0.471-0.723; p = 0.13) and of 0.737 (95% CI, 0.650-0.825; p <0.001), respectively.

Conclusion

In our cohort, the predictive score for complete clinical success of biliary stenting in UMBO (at 6 weeks) had a good accuracy (AUROC 0.74), similar to the AUROC reported by this study group (AUROC 0.76 in the validation cohort). The main advantage of this score relies on the fact that it can be applied before ERCP, since its variables can all be determined pre-endoscopically or, at the most, by the time of ERCP (type of stent), possibly allowing the definition of a better strategy for the management and follow-up of these patients.

References

Pausawasdi, N., Termsinsuk, P., Charatcharoenwitthaya, P., Limsrivilai, J., & Kaosombatwattana, U. (2022). Development and validation of a risk score for predicting clinical success after endobiliary stenting for malignant biliary obstruction. PloS one, 17(8), e0272918. https://doi.org/10.1371/journal.pone.0272918

Introduction

Eosinophilic esophagitis (EoE) is a chronic, condition linked to a type 2 inflammatory response and frequently associated to other atopic conditions. EoE may presents either sporadically, or with aggregation of cases within a same family. Limited information has been provided on the differences in clinical characteristics and disease features between sporadic and familiar EoE, largely due to the lack of large patient cohorts.

Aims & Methods

To find differences in sporadic and familiar cases of EoE which may support distinct clinical management, a cross-sectional analysis of the multicenter EoE CONNECT registry was performed. Demographic and clinical from patients recruited at 42 hospitals in 4 European countries were extracted on March 28th, 2025. Information extracted included 1) age at diagnosis and diagnostic delay; 2) symptoms leading to diagnosis; 3) disease endoscopic and histologic features at diagnosis; and 4) atopic concomitances.

Results

	S-EoE	F-EoE
Age at diagnosis (n= 3,179) <18 years old	18.5%	30.6%
Inflammatory Score (n= 2,723)	1.62 ± 1.3	1.93 ± 1.32
Fibrosis Score (n=2,723)	1.04 ± 1.04	0.97 ± 1.08
Fibrosis (n=1,701)	58.6 %	62.8 %
EoE-Phenotype (n=3,017)
Inflammatory	75.9 %	79.6 %
Mixed	12.6 %	8.6 %
Stricturing	11.5 %	11.8 %

Overall, 4,053 patients (75.4 % males, mean age 33.3 ±15.2 years) were analyzed, including 3028 (74.7 %) sporadic (S-EoE), 714 (17.6%) without familiar data and 311 (7.7 %) familiar (F-EoE) cases including 89 families. Among the family forms, n= 76 families showed 2 affected members, n= 11 presented 3 members, and n= 2 with 4 members. In 85/89 families we identified the index case consisting in sons (13), parents (23), siblings (38), or other distant kinships.
The F-EoE forms were diagnosed at younger mean ± SD ages than S-EoE (29.8±15.6 vs. 33.7±15.1; p<0.001) and included a higher proportion of pediatric patients (considered as those below 18 at diagnosis; 30.6% vs. 18.5%; p<0.001)
Symptoms leading to EoE diagnosis were similar across study groups, with slightly higher presences of abdominal pain (as they included more pediatric cases; 7.7% vs. 4.5%; p=0.01) and chocking episodes (7.7% vs. 4.5%; p=0.01) among F-EoE.
Endoscopy presented more severe features according to EREFS among F-EoE (mean ± SD being 2.86 ± 1.66 vs. 2.64 ± 1.68; p=0.054) at the expense of both fibrotic and inflammatory features, despite only the later reach statistical significance (1.93 ± 1.32 vs. 1.62 ± 1.3; p<0.001). Esophageal biopsies exhibited higher mean ± SD peak eosinophil counts in F-EoE cases (57.11 ± 40.7 vs. 52.87 ± 37.97; p=0.04).
F-EoE were more allergic patients, as they presented a higher mean ± SD number of concomitant atopies (1.44 ± 1.25 vs. 1.25 ± 1.22; p=0.009) and all were more common among them, with conjunctivitis and hives reaching statistical significance (p=0.01 and p=0.002 respectively). Overall, a higher proportion of F-EoE had at least one atopy compared to S-EoE (69.4 % vs. 63.8%).

Conclusion

F-EoE seems to present more severely, with earlier onset, more inflammatory load in endoscopy and biopsies and higher concomitant allergic manifestations.

Introduction

While patients with Sickle Cell Disease (SCD) often exhibit digestive manifestations, the underlying pathophysiology remains poorly understood. SCD could notably affect the intestinal mucosa through microvascular phenomena. Co-occurrence of SCD and Inflammatory Bowel Diseases (IBD) has been reported in a very limited number of cases.
Our aim was to explore the intersection between SCD and IBD, particularly focusing on the impact of SCD on the natural course of IBD and the safety profile of drugs in this high-risk population.

Aims & Methods

We conducted a multicenter retrospective case-control study involving all adult patients diagnosed with both IBD and concomitant SCD and followed in 3 tertiary university hospitals. Each IBD patient with SCD was matched with up to 4 IBD patients without SCD, based on disease phenotype (UC or CD), sex, date of birth (±3 years), length of disease follow-up (±2 years), and year of diagnosis (±3 years). The primary outcome was a complicated disease course, defined by a composite outcome including intestinal resection, perianal surgery, and/or the need for advanced therapy.

Results

Overall, 125 patients with IBD were studied, including 24 with concomitant SCD and 101 controls. Of the 24 SCD patients, 5 (20.8%) had Crohn's disease (CD), 17 (70.8%) had ulcerative colitis (UC) and 2 (8.3%) had indeterminate colitis. 23/24 (95 %) had colonic involvement. Of note, 8 of 24 (33.3%) SCD patients had concomitant primary sclerosing cholangitis (PSC) compared to 1% of patients in the control group (p<0.001). Survival without a complicated course of the disease was estimated at 58.7 % (IC95[49.6-69.5]) at 5 years and at 38.9% (IC95[29.9-50.4]) at 10 years, for non-SCD patients, and at 63.3% (IC95[45.7-87.6]) and 52.7% (IC95[34.9-79.6]) at 5 and 10 years, respectively, for patients with SCD and IBD (p=0.36, Log-rank test). The survival without the need of advanced therapy was estimated at 66.1% (IC95[57.3-76.2]) at 5 years for non-SCD patient, and at 78.2% (IC95[63-97.2]) in patients with SCD patients (p=0.45).
Regarding the safety profile, 26.3% (5/19) of patients with SCD and 13.5 % (14/104) of controls experienced adverse events with advanced therapies (p=0.17, Fisher’s exact test). There was one reported vaso-occlusive crisis associated with the use of thiopurines. No death occurred during follow-up.

Conclusion

While patients with SCD and IBD displayed a distinctive phenotype characterized by nearly constant colonic involvement and a high prevalence of associated PSC, the disease natural history of IBD did not differ from that of patients without SCD. Given the notable prevalence of PSC, systematic screening with cholangio-MRI should be considered. Furthermore, no significant safety signal regarding the use of immunomodulator or advanced therapy was raised.

Introduction

Preliminary data (PanCo) has suggested combined chemotherapy and endoscopic ultrasound (EUS) guided intra-tumoral phosphorus-32 (³²P) microparticles (OncoSil^TM Medical) may be beneficial in locally advanced pancreatic cancer (LAPC)¹. We report on the clinical outcomes in our Australia and New Zealand (ANZ) cohort with this combined therapy in LAPC.

Aims & Methods

This is a two-centre retrospective study from August 2017 – January 2023. All patients with non-metastatic unresectable or borderline resectable LAPC who underwent combination chemotherapy with EUS-guided intra-tumoral ³²P implantation were included from two centers in ANZ. First-line chemotherapy includes 5-fluorouracil/leucovorin, irinotecan and oxaliplatin (FOLFIRINOX) and gemcitabine and nab-paclitaxel (GNP). Outcomes including 12-week response (RECIST 1.1), resection rate and overall survival were recorded and compared between FOLFIRINOX and GNP cohorts.

Results

A total of 49 patients (male:32; median age:72 years) underwent combined therapy (FOLFIRINOX:19, GNP:30). A median ³²P microparticle volume of 1mL (IQR 0.8-1.6) was injected into pancreatic tumors (median longest diameter:29.5mm (IQR 26.7-37)). Technical success of ³²P implantation was 100% with no acute complications. Local disease control in patients 12 weeks post-implant was 96%. Fifteen patients (31%; 26.3% of patients with FOLFIRINOX vs. 33.3% of patients with GNP, p=0.074) had tumor downstaging and were theoretically resectable whilst 9 (18.4%) had successful resections (6/9 R0). Two patients are awaiting resection, one patient opted not for surgery and three patients were deemed not fit for surgery. Over a median follow-up period of 20 months (range 3-67), 55% (27/49) have had disease progression (36% local progression, 42% distant progression). Median overall survival from diagnosis was 16 months (IQR 11-21; FOLFIRINOX=14.6 months vs. GNP=16.6 months, p=0.259).

Conclusion

This is the largest reported ANZ cohort with EUS-guided ³²P implantation for patients with LAPC. Additionally, this is the largest reported cohort of patients with combined therapy with FOLFIRINOX. The results of this current study are encouraging, forming a platform for larger trials and further ANZ involvement in investigating the benefits of combined therapy in patients with LAPC. Studies comparing standard therapy and combined chemotherapy with ³²P implantation are warranted.

References

1. Ross, P.J., et al., PanCO: An open-label, single-arm pilot study of phosphorus-32 (P-32; Oncosil) microparticles in patients with unresectable locally advanced pancreatic adenocarcinoma (LAPC) in combination with FOLFIRINOX or gemcitabine + nab-paclitaxel (GNP) chemotherapies. Journal of Clinical Oncology, 2019. 37(15_suppl): p. 4125-4125

Introduction

Colon Capsule Endoscopy (CCE) offers a non-invasive alternative to colonoscopy for lower gastrointestinal (GI) investigations. However, its adoption is limited by lengthy reading times, reader fatigue, and variable diagnostic accuracy. These factors are often influenced by bowel preparation quality and completion rates. Artificial intelligence (AI) has shown the potential to improve diagnostic accuracy of polyp detection and reduce reading times in capsule endoscopy.

Aims & Methods

Objective(s): The primary aim is to assess the diagnostic accuracy of Computer-Aided Detection (CADe) system (AiSPEED™) assisted CCE reading using full-video analysis in a real-world clinical setting. Secondary outcome was to assess a) non-inferiority compared to standard clinician reading in detecting polypoid lesions and b) mean reading time.
Methods: CESCAIL study is a multi-centre study of 14 UK centres recruited 720 participants between November 2021 and September 2024. Participants (prospectively and retrospectively enrolled ) included those ≥18 years referred for CCE under the urgent cancer pathway or for post-polypectomy surveillance. CCEs were performed using PillCam™ COLON 2 and analysed using AiSPEED™. CCE videos were evaluated by separate clinicians who provided standard readings, while AI-assisted reading included an AI-assisted pre-reader review and subsequent clinician validation.

Results

720 patients were enrolled, with 673 included in the final analysis. The capsule excretion rate before battery depletion was 77.1%, with adequate bowel preparation achieved at 78.1% (with standard) and 74.0% (with AI-assisted reading) (McNemar p=0.108). In the per-patient analysis, the diagnostic yield for detecting polyps was 63.6% (428/673) for standard reading and 70.6% (475/673) for AI-assisted reading, using the expert panel as the reference standard. These findings confirmed both non-inferiority (p<0.001) and superiority (p<0.001) of the AI-assisted reading. The diagnostic accuracy for detecting polyps requiring follow-up procedure (flexible sigmoidoscopy/colonoscopy) was 0.96 (95% CI: 0.95–0.98) for AI-assisted reading, compared to 0.91 (95% CI: 0.89–0.93) for standard reading (p<0.0001) (see Table 1). The mean reading time per video was 8.7 minutes for AI-assisted reading compared to 47.3 minutes for standard reading, representing a 5.4-fold reduction.

Table 1: Per-Patient Outcome Summary (3 different endpoints) (n = 673)
Clinical outcome	Presence or Absence of Polyp (Per-Patient)			Polyp size≥ 6mm or ≥3 Polyps (Per-Patient)			Polyp size≥ 10mm or ≥5 Polyps (Per-Patient)
NHS England Guideline (11, 12)	Colonoscopy (Tier 1-3) vs no follow-up (Tier 4)			Polyp size≥ 6mm or ≥3 polyps (Tier 1-2) vs Polyp size <6mm or <3 (Tier 3-4)			Urgent Colon (Tier1) vs Other Outcome (Tier 2-4)
ESGE guidline (13)	-			ESGE 2012 guideline: Colonoscopy vs 5-year surveillance			-
Performance measures (%) (DTComPair)	Standard Arm (95% CI)	AI-assisted Arm (95% CI)	P value (McNemar’s)	Standard Arm (95% CI)	AI-assisted Arm (95% CI)	P value (McNemar’s)	Standard Arm (95% CI)	AI-assisted Arm (95% CI)	P value (McNemar’s)
Sensitivity	0.88 (0.85, 0.91)	0.96 (0.95, 0.98)	<0.001***	0.87 (0.84, 0.90)	0.96 (0.94, 0.98)	0.004**	0.90 (0.87, 0.93)	0.96 (0.93, 0.98)	0.004**
Specificity	0.99 (0.97,1.00)	0.96 (0.93,0.99)	0.058	0.99 (0.98,1.00)	0.96 (0.94,0.99)	0.035*	0.97 (0.95,0.99)	0.97 (0.96,0.99)	0.81
PPV	1.00 (0.99,1.00)	0.98 (0.97, 0.99)	0.071	1.00 (0.99,1.00)	0.98 (0.97, 0.99)	0.043*	0.97 (0.96,0.99)	0.98 (0.96, 0.99)	0.72
NPV	0.76 (0.71-0.82)	0.91 (0.88,0.95)	<0.001***	0.80 (0.75-0.85)	0.92 (0.86,0.95)	<0.001***	0.90 (0.87-0.93)	0.95 (0.93,0.97)	0.004**
Diagnostic accuracy	0.91 (0.89-0.93)	0.96 (0.95-0.98)	<0.001***	0.91 (0.89-0.93)	0.96 (0.94-0.97)	<0.001**	0.94 (0.92-0.95)	0.96 (0.95-0.98)	0.017*

Conclusion

AI-assisted reading with AiSPEED™ offers the potential for greater accuracy in polyp detection and significantly reduced clinician reading times during CCE examination compared to standard reading methods.

References

1. Moen S, Vuik FER, Kuipers EJ, Spaander MCW. Artificial Intelligence in Colon Capsule Endoscopy-A Systematic Review. Diagnostics (Basel). 2022;12(8).
2. Mota J, Joao Almeida M, Mendes F, Martins M, Ribeiro T, Afonso J, et al. A Comprehensive Review of Artificial Intelligence and Colon Capsule Endoscopy: Opportunities and Challenges. Diagnostics (Basel). 2024;14(18).
3. Spada C, Piccirelli S, Hassan C, Ferrari C, Toth E, Gonzalez-Suarez B, et al. AI-assisted capsule endoscopy reading in suspected small bowel bleeding: a multicentre prospective study. Lancet Digit Health. 2024;6(5):e345-e53.
4. Spada C, Hassan C, Galmiche JP, Neuhaus H, Dumonceau JM, Adler S, et al. Colon capsule endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2012;44(5):527-36.
5. PillCam COLON 2 for investigation of the colon through direct visualisation [Internet]. NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE. August 2024. Available from: https://www.nice.org.uk/guidance/gid-dg10083/documents/final-scope-2.

Disclosure

Hagen Wenzek serves as the CEO, and Elizabeth White is the Project Manager at Corporate Health International which owns the ​intellectual property of AiSPEED^TM