Introduction

Incidence and mortality rates of acute pancreatitis (AP) vary and often rely on old surveys. Likewise, the type of organ failure and consequent interventions have only been reported in a few recent reports.[1-3] We thus compiled German-wide data on morbidity and mortality of AP using the Diagnosis-related group (DRG) coding system.

Aims & Methods

All German hospitals have to report DRG codes to the federal statistical office. We analysed this database of the years 2018 and 2019 for selected DRG Codes.[4] The derived information was classified as reliable, acceptable or prone to bias depending on the reported code (e.g. mandatory information or not).

Results

In 2018 and 2019 109.064 patients with the main diagnosis AP were treated in German hospitals. This corresponds to an incidence of 65.5/100.00 person-years. The median age was 57 (IQR 45-71), 60.8% were male and 22.0% had an acute on chronic pancreatitis. The median hospital stay was 6 days (IQR 4-10), while 5.2% were discharged within 1 day. According to the DRG codes, 7.3% suffered respiratory failure, 6.4% renal failure (acceptable information), 1.6% circulatory failure and 0.6% liver failure (information prone to bias). 1.3% of the patients received renal replacement therapy and 0.06% ECMO therapy. A pancreatic drainage was performed in 1.8 % of the patients. In 73% of these cases an internal drainage was applied. A necrosectomy was performed in 1.1% of the patients and 0.8% received therapy with Caspofungin (reliable information). In total, 3.5% of the patients were admitted to an intensive care unit , 3.6% were put on ventilation, and 3.1% on invasive ventilation. According to the revised Atlanta classification 86.8% of the patients had a mild pancreatitis while 13.2% suffered at least one coded organ failure or local complication (moderately severe and sever AP). Overall mortality was 2.4% (1.6/100.000 persons, reliable information). Patients with at least one coded organ failure or local complication suffered a mortality rate of 14.9 %, in patients that were either treated for local complications, ventilated or dialysed (5.5% of the patients, corresponding to a severe AP) the mortality rate was 24.9% (reliable information).

Conclusion

The incidence of AP is notably higher than previously reported and patients with systemic or local complications still suffer a substantial mortality. However, recent mortality rates in Germany appear to be on the lower side of the reported range.

References

1. Iannuzzi, J.P., et al., Global Incidence of Acute Pancreatitis Is Increasing Over Time: A Systematic Review and Meta-Analysis. Gastroenterology, 2022. 162(1): p. 122-134.
2. Sternby, H., et al., Determinants of Severity in Acute Pancreatitis: A Nation-wide Multicenter Prospective Cohort Study. Ann Surg, 2019. 270(2): p. 348-355.
3. Xiao, A.Y., et al., Global incidence and mortality of pancreatic diseases: a systematic review, meta-analysis, and meta-regression of population-based cohort studies. Lancet Gastroenterol Hepatol, 2016. 1(1): p. 45-55.
4. Source: RDC of the Federal Statistical Office and Statistical Offices of the Länder, DRG Statistik, own calculations. 2018-2019.

Introduction

Esophageal squamous cell carcinoma (ESCC) can be treated curatively with definitive chemoradiotherapy (CRT). However, local failure, characterized by residue just after CRT or recurrence after achieving complete response with CRT, occurs in 20-40% of patients who received this treatment. Salvage endoscopic therapy is one of the treatment options for cT1N0N0 local failure after CRT or radiotherapy (RT) for ESCC, but most reports on its outcomes are at single center.

Aims & Methods

This multicenter study aimed to clarify the short- and long-term outcomes of salvage endoscopic therapy (endoscopic resection [ER: EMR/ESD] and photodynamic therapy using Talaporfin Sodium [PDT]) for cT1N0M0 local failure after CRT/RT for ESCC, and to identify factors that influence the outcomes of salvage endoscopic therapy. Patients who underwent salvage endoscopic therapy (ER, PDT) for cT1N0M0 local failure after CRT/RT for ESCC at two institutions between December 2012 and August 2021 were retrospectively investigated. The patients were excluded if they were not followed up for more than three months after salvage therapy or had a history of salvage therapy. The selection of the procedure was primarily based on the depth of the tumor and the degree of submucosal fibrosis.

Results

A total of 168 patients were analyzed, of which 86 underwent ER (EMR/ESD = 15/71) and 82 underwent PDT. Among the patients, 140 were male, and the median age was 72 (range: 45-88) years. Lesion characteristics were as follows: The clinical T stage before CRT/RT; T1a/T1b/T2/T3/T4a/unknown = 5/78/24/48/9/4 cases. Local failure before salvage therapy; residual/local recurrent lesions = 107/61 cases. Clinical tumor depth before salvage therapy; EP-LPM/MM-SM1/SM2-SM3 = 54/35/79 cases. 53 of the 54 patients with a tumor depth of EP-LPM underwent ER, while 73 of the 79 patients with a tumor depth of SM2-SM3 underwent PDT. The local complete response rate in PDT was 62% (50/81 patients, 1 not evaluated), and the R0 resection rate in ER was 73% (63/84 patients, 2 not evaluated due to burn effect). One patient in the PDT group died from massive gastrointestinal bleeding due to esophageal-aortic fistula on the 69th day after PDT. The median observation period was 33.5 (2-109) months, and the three-year overall survival (OS), disease-specific survival, local recurrence-free survival (LRFS), and esophagectomy-free survival rates were 79% (95% confidence interval: 71-86%), 88% (80-93%), 54% (46-62%), and 76% (67-82%), respectively. Multivariate analysis revealed that age ≥75 years and residual lesion just after CRT were independent risk factors of OS (p = 0.039 and p = 0.024, respectively). Clinical tumor depth was not a significant risk factor for OS and LRFS. The clinical course after salvage treatment was as follows: 93 patients had no recurrence; 28 patients had lymph node and/or distant metastatic recurrence with/without local failure. Of the 53 patients with local failure (residual: 33, local recurrence: 20) after initial salvage endoscopic therapy, 46 underwent re-salvage therapy (ER: 11, PDT: 27, surgery: 8), and 24 of them are alive without the recurrence of ESCC, while 8 died from the primary disease.

Conclusion

Our results suggest that salvage endoscopic therapy including ER or PDT appears to be an effective treatment option for cT1N0M0 local failure after CRT/RT, regardless of clinical tumor depth, resulting in a certain number of patients achieving long-term survival without the primary disease and preserving their esophagus.

Introduction

Colonic stents (CS) are usually placed for palliative purposes in patients with malignant obstructions(1). Paucity of data exist in regards causes, rates, mortality and predictors of readmission.

Aims & Methods

Retrospective review of the National Readmission Database (NRD) of the year 2019 of adult patients that underwent CS placement during an index admission (IA) from the month of January to November and were readmitted within 30-days of discharge. ICD-10CM/PCS codes were utilized to identified the procedures and comorbidities. The primary outcome was readmission of any cause. Secondary outcomes were mortality, resource utilization (length of stay (LOS), total hospitalization costs and charges) associated with readmission. Independent risk factors for readmission were identified using Cox regression analysis.

Results

A total of 2,786 patients underwent CS placement in 2019. 46.4% of patients were female and mean age was 65.6 years, most of the patient had a Charlson Comorbidity Index (CCI) score of ≥3 (62.4%) and 44.6% of stents were placed to relieve a malignant obstruction. The 30-day readmission rate was 29.1% (N=811), the most common diagnosis associated with readmission was neoplasm of the sigmoid colon (64.3%). The mortality rate of readmission was 6.7% and 4.5% for the IA (P<0.01). A higher proportion of females were readmitted (50.8% vs. 44.5%, P=0.04), readmitted patients had lower rates of CCI score of ≥3 (55.3% vs. 65.3%), more likely to be from large metropolitan areas with at least 1 million residents (70.4% vs. 64.1%, P=0.04), to have associated obesity (17.8% vs. 11.5%). Patients that had CS placed for obstruction (45.1% vs. 39.3%; P=0.04) and colonic fistula (2.9% vs. 1.2%; P=0.02) were more likely to be readmitted. The mean LOS, hospitalization charges and costs were: 10.4 days, $93,780 and $24,758, respectively. The total cumulative hospitalization charges and costs associated with readmission were $76.2 million and $20.1 million. Independent predictors of 30-day readmission were obesity [adjusted Hazard Ratio (aHR) 1.40, 95% Confidence Interval [CI] (1.07-1.85)], stent placement for colonic fistula [aHR 2.92 (1.74-4.90)], stent placement in the descending colon [aHR 1.40(1.03-1.90)] and residence in not metropolitan or micropolitan [aHR 3.25(1.35-7.85)].

Conclusion

Readmissions after CS placement are high. The mortality rate associated with readmission is significantly higher than in the IA. Obesity increases the risk of readmission by 1.4 times. Further prospective studies are needed to evaluate the mechanisms and causes to decrease readmission rates and in-hospital mortality in this set of patients.

References

1. Navaneethan U, Duvuru S, Jegadeesan R, Venkatesh PG, Gutierrez NG, Hammel J, Kiran RP, Sanaka MR. Factors associated with 30-day readmission and long-term efficacy of enteral stent placement for malignancy. Surg Endosc. 2014 Apr;28(4):1194-201. doi: 10.1007/s00464-013-3308-6. PMID: 24232056

Introduction

Despite undeniable advantages as higher en-bloc and curative resection rates, better carcinologic outcomes and lower recurrence rates, endoscopic submucosal dissection (ESD) is associated with more adverse events, than piece-meal endoscopic mucosal resection, limiting its spread in the West. However, risk factors in western patients and clinical implications of perforation are not well known.

Aims & Methods

This is a prospective cohort including all colorectal ESD performed in 12 French centers and 1 Belgian center between September 2019 and September 2022, with additional retrospective analysis of patients with per-procedural or delayed perforations.
The objectives of this study were to analyze prevalence, risk factors and clinical outcomes of perforation following colorectal ESD.

Results

Per-procedural perforations (PPP) (n=354) or delayed perforation (DB) (n=20) occurred in 374/4025 procedures, with a mean ±SD lesion size of 54 ±26 mm, and median procedure time of 57 min (IQR 34-90).
In the perforation group, lesions were larger (60 ±32 mm vs 53 ±25 mm, p= 0,001), with lower resection speed (25 ±21 mm2/min vs 35 ±24 mm2/min) and presented more severe fibrosis (55,5% vs 26,2%, p<0,0001). En-bloc (87,2% vs 95,8%), R0 (74,0% vs 89,0%) and curative resection (71,2% vs 85,2%) rates were lower in the perforation group (all p<0,0001).
Non-granular laterally spreading tumors (LST) was a risk factor of both PPD (p=0,036) and DP (p<0,0001). Female sex was associated with PPP (p=0,019) but not with DP (p=0,714).
PPP were more frequent in intermediate-volume centers compared to low and high volume (p<0,0001), but there was no difference regarding the risk of DP (p=0,949).
Poor manoeuvrability was associated with PPP (p<0,0001) but not with DP (p=0,351).
PPP were particularly frequent in the splenic (21/102 lesions, 19,0%) and hepatic (30/184 lesions, 16,3%) flexures and in the appendix (20/118, 16,9%), with statistical significance (p<0,0001). All DP occurred in the colon but there was no statistical difference between the different segments.
Prophylactic closure of the scar did not prevent DP (OR 1,22 95%CI 0,41-1,22).
By calculation of area under the curve (AUC), a threshold of ³ 70 mm was identified as predictive for immediate perforation (p<0,0001).
In multivariate analysis, lesion ³ 70 mm (OR 2,17 95%CI 1,50-3,15), speed of resection (OR 0,98 95%CI 0,97-0,99), female sex (OR 1,30 95%CI 1,01-1,68), poor maneuverability (OR 1,53 95%CI 1,15-2,03) and severe fibrosis (OR 3,2 95%CI 2,30-4,4,43) were predictive of PPP.
Regarding clinical burden, DP required surgery in most of the cases (17/20, 85%) whereas PPP were treated conservatively (13/354 emergent surgeries, 3,7%) (p<0,0001). Stoma was performed in 37,5% of cases. Among rectal perforations, no closure was done in 23% of cases without the need for surgical or radiological interventions.
In colonic PPP, the need for peritoneal exsufflation or the type of closure (TTS clips vs OTS clips) were not associated with surgery. CRP and white cell blood levels on day 1 after ESD were not different between groups but fever was associated with surgery (OR 9,41 95%CI 2,44-36,29).

Conclusion

In this large study, risk factors for per procedural perforations could be identified and conservative treatment appears effective. Delayed perforations are rare and cannot be predicted but require surgery in most of the cases. This could help the patient and the physician to choose the best treatment with balance of benefices and risks.

Introduction

Recent evolution of image-enhanced endoscopy (IEE) makes it possible to detect ESCC easily. However, we sometimes encounter the cases where IEE cannot detect ESCC. Iodine staining is a gold standard, but it cannot be used for those with allergy to iodine. We developed a novel fluorescence probe (EP-HMRG). EP-HMRG emits green fluorescence immediately after being cleaved by DPP-IV, which is overexpressed in ESCC. The advantages are its ability to be applied topically and its fast reactivity. We confirmed that EP-HMRG achieved high accuracy for ESCC (＞ 90%) even 5 minutes after application using biopsy samples (Sci Rep, 2016).

Aims & Methods

Our aim of the present study is to investigate the safety and feasibility of EP-HMRG through a first-in-human trial. This is a phase 1 trial to assess the safety and efficacy of EP-HMRG for ESCC patients. Those who were scheduled to undergo endoscopic resection (ER) for ESCC were enrolled in this study. After 20 mL of 50 μM EP-HMRG solution was sprayed into the esophagus, one biopsy was taken from each fluorescent and non-fluorescent area under the observation with the prototype fluorescence endoscope. The biopsy specimens were blinded and diagnosed by one board-certified pathologist; ER was performed the day after EP-HMRG spraying, and the patient was discharged 5 days after treatment.

Results

A total of 6 patients were recruited between November 2019 and February 2021. 4 of the 6 patients complained of mild dysphagia and chest pain after ER, which were attributed to ER itself. No adverse events related to EP-HMRG occurred. Fluorescence endoscopy revealed strong fluorescent areas in the esophagus in 3 patients and weak fluorescent areas in the remaining 3 patients. Biopsy pathology results showed that no cancer was proved in any of the non-fluorescent areas. SCC was proved in 4 of the 6 specimens of the fluorescent sites. In 2 cases where the fluorescence was weak, no cancer was proved in the biopsy specimens taken from fluorescent areas. Positive predictive value, negative predictive value and accuracy were 67%, 100%, and 83%, respectively.

Conclusion

Our first-in-human study of a novel fluorescent probe for ESCC revealed safety, whereas the diagnostic accuracy reached only 83%. One possible reason was that the detectability of the prototype endoscope did not reach the level of the dedicated fluorescent imaging device. The fluorescent endoscope used in this study was still under development, and the images were dark, which may have resulted in sampling errors or failure to capture fluorescence coloration. The development of a fluorescence endoscope that is comparable to a dedicated fluorescence imaging device is an issue to be addressed in the future.

Introduction

The diagnosis of advanced gastric cancer (AGC) is occasionally challenging for endoscopists. In particular, scirrhous gastric cancer (SGC) is often missed by esophagogastroduodenoscopy (EGD) alone because it may not form obvious ulcers or tumors. Early detection of SGC is difficult, and the prognosis is often poor. Considering the rapid progression of SGC, an accurate endoscopic diagnosis of the disease is desirable. SGC is diagnosed using computed tomography, EGD, and EGD-biopsy. In AGC, except for SGC, a definitive diagnosis can be made in >90% of cases when EGD findings are combined with EGD-biopsy. However, SGC is often difficult to diagnose even with EGD-biopsy. One report has indicated that the false-negative proportion of EGD-biopsy in SGC is >50%, because compared to other AGCs, SGC presents a variety of endoscopic findings, as well as special growth forms and morphological features. Therefore, the usefulness of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) instead of EGD-biopsy in the diagnosis of SGC has recently been reported, and the positive diagnosis proportion is as high as 71.4%–82.6%. Against this background, we believe that EUS-FNA is an alternative for diagnosing EGD-biopsy-negative SGC. Therefore, we conducted a systematic review and meta-analysis to analyze the EUS-FNA diagnosis rate from previous reports in the diagnosis of SGC, verify the advantages and disadvantages of EUS-FNA, and evaluate the utility of EUS-FNA for the current SGC diagnostic landscape.

Aims & Methods

A systematic review was conducted using the PubMed (MEDLINE) and Ichushi-Web (NPO Japan Medical Abstracts Society) data and included all entries since their inception to October 10, 2022, in which SGC was evaluated using EUS-FNA. The following electronic search terms were used to retrieve the literature in PubMed: ("endosonography"[MeSH] OR "endosonography"[tiab] OR “EUS”[tiab] OR "biopsy, fine needle"[MeSH] OR “fine needle aspiration”[tiab] OR “fine needle biopsy”[tiab]) AND ("linitis plastica"[MeSH] OR “linitis plastica”[tiab] OR "stomach neoplasms"[MeSH] OR “gastric cancer”[tiab]). Additionally, Ichushi-Web created an electronic search strategy based on the above words. The primary outcome was the proportion of SGC diagnosed using EUS-FNA. In addition, we analyzed the proportion of adverse events associated with EUS-FNA. The study protocol was registered in the UMIN Clinical Trials Registry on October 10, 2022 (No: UMIN000049169).

Results

The electronic search identified 1890 studies; overall, 4 studies met the selection criteria and reported data on EUS-FNA performed on 114 patients with suspected SGC. In our systematic review, the overall diagnostic yield of EUS-FNA for SGC was 82.6% (95% confidence interval, 74.6–90.6%) and the statistical heterogeneity was 0% (I² = 0%), indicating a low heterogeneity. Furthermore, the EUS-FNA diagnostic proportion for SGC lymph node metastasis was 75–100%, indicating a high diagnostic performance. No apparent adverse events were observed in these 4 studies.

Conclusion

We believe that EUS-FNA is a useful examination because of its minimally invasive nature and high tissue diagnostic proportion. In particular, we consider it to be a useful alternative examination for patients with suspected SGC who cannot be definitively diagnosed by CT or EGD-biopsy.