Introduction

Perihilar cholangiocarcinoma (pCCA) is a rare malignancy originating from the bile duct bifurcation which is often diagnosed in an advanced stage. Most patients require endoscopic or percutaneous biliary drainage, as they present themselves with jaundice and/or cholangitis. In most Western countries, only palliative chemotherapy (pCTx) is offered to these patients, positively impacting overall survival and quality of life. Unfortunately, median survival is still poor, with only 10.6 months in patients receiving pCTx, compared to a dismal 4.0 months in patients receiving best supportive care (1). For non-resected pCCA, there is much debate on the optimal technique of biliary drainage, which is often deemed necessary to initiate pCTx. This study aimed to investigate the impact of biliary drainage on pCTx initiation and survival in patients with non-resected pCCA.

Aims & Methods

Individual patient data from all Dutch patients diagnosed with non-resected pCCA between 2015 and 2020 were retrieved from the Netherlands Cancer Registry. Survival data was last updated on 1^st of February 2024. Data was retrieved and de-identified by trained data clerks. The primary outcome was pCTx initiation. Secondary outcome was overall survival. For both the primary and secondary outcome, associations were investigated for several (biliary drainage) factors by multivariable competing risk regression analysis. Initial drainage procedure and initiation of pCTx were treated as time-varying covariates. Sensitivity analysis for pathologically proven pCCA was performed.

Results

A total of 1265 patients (median age of 74 years [IQR: 66-82 years]) were included, of whom 242 patients (19.1%) received pCTx after a median interval of 72 days [IQR 43-110 days] after initial presentation. Patients who underwent biliary drainage did not receive pCTx more often. If performed, drainage at a referral hospital (HR:0.65, 95%CI: 0.42-0.99), ≥3 drainage procedures performed (HR:0.53, 95%CI: 0.32-0.88), and drainage performed ≥14 days after presentation (HR:0.70, 95%CI: 0.49-0.99) were associated with no pCTx. Median overall survival for those who received pCTx and those who did not was 12.8 months [95%CI: 11.7-14.2] and 2.7 months [95%CI: 2.4-3.1]. Receiving of pCTx was associated with improved overall survival (HR:0.61, 95%CI: 0.51-0.73), but biliary drainage was not. If performed, biliary drainage by percutaneous trans-hepatic catheter placement compared to endoscopic plastic stenting (HR:1.27, 95%CI: 1.02-1.57) was associated with diminished survival, and drainage performed ≥14 days after presentation (HR: 0.76, 95% CI: 0.65-0.88) was associated with improved overall survival. Sensitivity analysis for pathologically confirmed pCCA showed similar results.

Conclusion

The need for biliary drainage did not affect the initiation of pCTx. When indicated, biliary drainage should be performed as quick as possible in an academic center to improve the rate of patients receiving pCTx.

References

1. Izquierdo-Sanchez L, Lamarca A, La Casta A, Buettner S, Utpatel K, Klumpen HJ, et al. Cholangiocarcinoma landscape in Europe: Diagnostic, prognostic and therapeutic insights from the ENSCCA Registry. J Hepatol. 2022;76(5):1109-21.

Disclosure

J. de Vos-Geelen has served as a consultant for Amgen, AstraZeneca, MSD, Pierre Fabre, and Servier, and has received institutional research funding from Servier (all outside the submitted work). RPV reports a research grant and consultancy fees from Boston Scientific, research grant from Prion medical, Consultancy fee from Cook Medical, Speakersfee Viatris. N Haj Mohammad has served as a consultant for Merck, BMS, Astra Zeneca, Servier and has received institutional research funding from Servier. M.J. Bruno serves as a consultant and receives support for industry and investigator-initiated studies from Boston Scientific and Cook Medical and receives support for investigator-initiated studies from Pentax Medical, 3 M, Interscope, and Mylan. W.J. Lammers acts as a consultant/lecturer for Mediglobe. The remaining authors declare no conflicts of interests.

Introduction

A new LED endoscopy system featuring advanced noise-reduction technology for enhanced brightness and minimal halation, the EP-8000 with the EC-860ZP colonoscope (Fujifilm), is scheduled to be released.

Aims & Methods

We conducted a multicenter, observational study to evaluate the new system’s potential improvements in image quality compared to a previous system/scope (VP-7000/EC-760ZP). From January 2024 to January 2025, patients undergoing colonoscopy at two institutions were enrolled. Images of the cecum and lesions were captured using white light imaging (WLI), blue light imaging (BLI), and linked color imaging (LCI) under similar conditions about air insufflation, angle, distance, and so on. Participants were divided into three groups: Group 1 (EP-8000+EC-860ZP; 50 cases), Group 2 (EP-8000+EC-760ZP; 50 cases), and Group 3 (VP-7000+EC-760ZP; 50 cases). Cecal images were evaluated for brightness and halation using a four-point scale (1=poor to 4=excellent) by endoscopists and original values by image-analysis software, while lesion images were assessed for brightness, halation, and visibility by endoscopists.

Results

In cecal images, the endoscopists’ scores for WLI in Group 1 were significantly better than in Group 3 for brightness (3.71±0.55 vs. 3.51±0.58, p<0.001) and for halation (3.60±0.51 vs. 3.18±0.59, p<0.001). Similarly, for BLI and LCI, Group 1 achieved higher scores than Group 3 regarding brightness (BLI: 3.15±0.85 vs. 2.23±0.92, p<0.001; LCI: 3.83±0.42 vs. 3.54±0.58, p<0.001) and halation (BLI: 2.99±0.69 vs. 2.71±0.78, p<0.001; LCI: 3.33±0.60 vs. 3.10±0.58, p<0.001). Software analysis confirmed that Group 1 had superior brightness values compared to Group 3 for WLI (122.7±6.6 vs. 110.7±7.7, p<0.001), BLI (99.1±10.9 vs. 69.3±11.5, p<0.001), and LCI (139.4±9.2 vs. 113.1±10.7, p<0.001), as well as lower halation values for WLI (1.34±1.80 vs. 3.35±3.59, p=0.031) and LCI (1.48±0.83 vs. 4.06±3.99, p=0.010). Regarding lesion images, brightness, halation, and visibility for WLI, BLI, and LCI were significantly better in Group 1 than in Group 3.

Conclusion

The new LED system provided marked improvements in brightness, halation, and lesion visibility. The software assessment was consistent with endoscopists assessment objective and can be used for the development and evaluation of new endoscopic systems.

References

Nishizawa T, Toyoshima O, Yoshida S, et al. TXI (Texture and Color Enhancement Imaging) for Serrated Colorectal Lesions. J Clin Med 2021; 11: 119.
Okumura T, Hotta K, Imai K, et al. Efficacy of texture and color enhancement imaging for the visibility and diagnostic accuracy of non-polypoid colorectal lesions. DEN Open 2024; 29; 5: e380.
Antonelli G, Bevivino G, Pecere S, et al. Texture and color enhancement imaging versus high definition white-light endoscopy for detection of colorectal neoplasia: a randomized trial. Endoscopy 2023; 55 :1072-1080.
Yoshida N, Inagaki Y, Inada Y, et al. Additional 30-Second Observation of the Right-Sided Colon for Missed Polyp Detection With Texture and Color Enhancement Imaging Compared with Narrow Band Imaging: A Randomized Trial. Am J Gastroenterol 2024; 119: 539-546.
Aniwan S, Vanduangden K, Kerr SJ, et al. Linked color imaging, mucosal exposure device, their combination, and standard colonoscopy for adenoma detection: a randomized trial. Gastrointest Endosc 2021; 94: 969-977.
Yoshida N, Draganov PV, John S, et al. Comparison of LED and LASER Colonoscopy About Linked Color Imaging and Blue Laser/Light Imaging of Colorectal Tumors in a Multinational Study. Dig Dis Sci 2023; 68: 3943-3952.

Disclosure

Yoshida N and Dohi O received a research grant from Fujifilm Co. Yamamoto H had a consultant relationship with Fujifilm Co. and received honoraria, grants, and royalties from the company. Yano T received a research grant and honoraria from Fujifilm, Japan. The other authors declare no conflicts of interest. Novel endoscopic systems and scopes were lent by Fujifilm Co.

Clinical Case Summary

Concomitant biliary and gastric outlet obstruction is a frequent manifestation of gastrointestinal malignancies, especially pancreatic and biliary tumors. Classical treatment included surgical gastrojejunostomy and hepaticojejunostomy (double bypass), but minimally invasive endoscopic techniques have transformed this approach. Therapeutic endoscopic ultrasound (EUS) allows for EUS-guided double bypass (EUS-DB), though data on single-session procedures remain limited.
We present the case of a 55-year-old woman, ECOG PS 0, with a family history of Lynch syndrome, who presented in August 2024 with three weeks of nausea, vomiting, abdominal pain, jaundice, and dark urine. Labs showed microcytic anemia (Hb 10 g/dL) and elevated cholestatic markers (total bilirubin 5.0 mg/dL, AST 88 U/L, ALT 118 U/L, ALP 475 U/L, GGT 470 U/L); CA 19-9 was 1043 U/mL. CT revealed a large pancreatic head mass with duodenal invasion, gastroduodenal artery encasement, and liver metastases. Admitted for GI bleeding (Hb 5 g/dL), she was discussed in a multidisciplinary team meeting, and referred for gastroduodenal artery embolization, which proceeded uneventfully, followed by lesion biopsy, endoscopic hepatogastrostomy, and gastrojejunostomy. EUS-DB was performed on 21/08 uneventfully, confirming a poorly differentiated pancreatic carcinoma. She started palliative chemotherapy and 6 months later maintains stable disease, tolerating oral intake.
We briefly present our EUS-DB series (n=5), with 100% technical success, resolution of gastric outlet obstruction in all cases and biliary obstruction in 75%. All resumed oral intake the next day. Only this patient started oncologic treatment; the others had rapid progression.
These cases demonstrate the feasibility and safety of simultaneous EUS-guided gastrojejunostomy and hepatogastrostomy, reinforcing the need for careful patient selection to optimize outcomes.

Clinical Case Summary

Vertical banded gastroplasty (VBG) is a bariatric procedure which use the combination of staples and a band to create a small gastric pouch. Although its primary success, this procedure was not longer performed because of not ineffective weight loss over time and common complications such as stricture or complete obstruction at the level of the band side, resulting in vomiting and dysphagia.
A 59-year-old male presented to the ER with vomiting, significant weight loss, syncopal episodes and electrolyte imbalance. In his past medical history, he had a VBG performed in 2001 for obesity. These symptoms led him to visit different hospitals over the years. No diagnosis could be made, due to the presence of alimental residual every time he performed an esophagogastroduodenoscopy (EGD). Eventually, after different years, he came to our center. Since the high risk of finding alimental residual in the stomach, the EGD was performed under general anesthesia. After reaching the stomach, we observed the complete obliteration at the site of the bendage, and the presence of a bezoar inside the small gastric pouch, resulting in outflow obstruction. Behind the bezoar, the presence of a natural gastro gastric fistula was observed at the sight of the previous staple line. The remnant part of the stomach was explored, showing sign of mucosal atrophy. On retroflexion, the region of the band site was obstructed, and covered by normal mucosa, suggesting a complete embedment of the gastric bandage. During the years, the complete obliteration at the bendage site resulted in an increase in pressure inside the gastric pouch. This led to the formation of a gastro-gastric fistula, to allow the patient to feed himself. Once the bezoar has formed, this “mechanism” failed, resulting in symptoms of outlet obstruction. The bezoar was removed using a grasping forcep. After the remotion of the bezoar, he managed to resumed oral feeding, in the absence of vomiting or nausea.

References

1. Endoscopic removal of the bezoar using a net retriever
2. Endoscopic appearance of the gastro-gastric fistula
3. Endoscopic appearance of gastric bendage completely buried into the mucosa

Introduction

The prognosis for patients with hepatocellular carcinoma (HCC) remains extremely poor, with a 5-year survival rate of 20% without curative treatment. A recent studyⁱ demonstrated that the use of a computed CT score including muscle density and muscle area could identify frailty in cirrhotic patients and predict 6-month mortality. The objective of the study was to evaluate predictors of 6-month mortality in patients with HCC and to establish the impact of sarcopenia in this context.

Aims & Methods

We performed a retrospective analysis of 86 patients with HCC treated at the Hôtel Dieu de France in Beirut between 2016 and 2024. The collection included clinical and biological data, prognostic indices (Child Pugh scores, MELD) as well as CT parameters for measuring sarcopenia and myosteatosis, including skeletal muscle index, muscle densities, and muscle surfaces at L3 level. The coreslicer® software was used to calculate muscle and fat surfaces on CT. The measurements evaluated included the surfaces at L3 of the psoas and paravertebral and parietal muscles, as well as the density of the psoas. Among these, the “L3 skeletal muscle area adjusted to height and density ratio (L3- SMHDR)” which is calculated by the total muscle area at the L3 level * Average size / density of the psoas muscles at the L3 level. This measurement helps include myosteatosis in the assessment of sarcopenia.

Results

• Our population included 86 patients with HCC, 74 men, 12 women, with a mean age of 66.1 ± 10.7 years. MELD-Na score was 16.1 ± 8.2, and Child-Pugh score was A, B, and C in 39%, 27%, and 34%, respectively. Twelve patients (14%) were eligible for curative treatment, in accordance with BCLC guidelines.
• Decreased survival is significantly associated with increasing L3-SMHDR. An AUROC analysis for L3-SMHDR as a predictor of mortality at 1 month found the same cutoff values as a previously published study with cutoffs of 5.4 and 4.7 in men and women, respectively. Populations with low L3-SMHDR vs. high L3-SMHDR had a survival time of 31.2 months vs. 11.09 months (P=0.035).
• In order to determine the different factors linked to a decrease in survival at 6 months, we conducted a univariate analysis which identified the following parameters: muscle density at scan (p=0.016), L3-SMHDR (p=0.004), L3-DRMI (p=0.034) and the MELD-Na score (P=0.077). A value of L3-SMHDR > threshold had a risk of mortality OR= 7.8 [1.8-34, P=0.003] and 5.64 [1.3-23.8, P=0.013] at 6 and 12 months respectively.
• In multivariate analysis, the two independent prognostic factors were the MELD-Na score and L3-SMHDR, which allowed us to arrive at the following equation:
• Probability = 0.112* MELDNa + 2.518* L3-SMHDR – 3.11.
• This analysis allowed us to classify patients according to the above function categories, and to estimate the risk of mortality at 6 and 12 months at respectively OR = 10 [2-50, P=0.003] and 11.4 [2.2-58.6, P=0.002].

Conclusion

The 6-month prognosis of patients with HCC depends primarily on liver function and the severity of sarcopenia and myosteatosis, not tumor stage. This should provide additional prioritization for patients eligible for liver transplantation. Confirmation of these results should be considered in a larger-scale study.

References

i. El Khoueiry C, Slim R, Rida M, Khoury B, Honein K, Smayra T, Yaghi C. New Scanographic Index for the Detection of Frailty in Patients with Cirrhosis with a Prognostic Impact. Middle East J Dig Dis. 2024 Apr;16(2):102-108. doi: 10.34172/mejdd.2024.376. Epub 2024 Apr 30. PMID: 39131107; PMCID: PMC11316193.

Introduction

Liver fibrosis stands out as the main prognostic risk factor in MASLD. The enhanced liver fibrosis (ELF) score is a composite of direct fibrosis biomarkers that reflect extracellular matrix turnover. While the ELF test exhibits high diagnostic accuracy for advanced liver fibrosis in MASLD patients, its role as a prognostic biomarker remains uncertain.

Aims & Methods

Our aim is to compare the prognostic effectiveness of ELF, liver stiffness measurement (LSM), FIB4, and liver histology in patients with MASLD.
We retrospectively enrolled patients with MASLD who underwent liver biopsy between 2013 and 2023. The ELF score was automatically using a serum sample collected at baseline. FIB4 computation, LSM with Fibroscan and liver biopsy were performed at baseline. Liver fibrosis stage was assessed according to the NASH CRN Scoring System. The primary outcome was a composite endpoint including all-cause mortality, hepatocellular carcinoma, liver transplantation or complications related to cirrhosis (ascites, variceal bleeding, hepatic encephalopathy, MELD≥15). Subjects were stratified based on existing literature cut-offs for ELF (<9.8, 9.8-11.2, >11.2), LSM (<10, 10-15, >15 kPa), FIB-4 (<1.3, 1.3-2.67, >2.67), and histology (F≤2, F3, F4) to assess the risk of occurrence of the primary outcome.

Results

We included data of 289 patients (30.4% female, median age 50y [IQR 39-58]). Over a median follow-up time of 41 months (IQR 21-68), the composite endpoint occurred in 34 (11.8%) patients. The frequency of the primary outcome exhibited a stepwise increase with ELF scores <9.8 (0.5%), 9.8 to 11.2 (14.5%) and >11.2 (69.7%). Survival curves for comparisons between groups revealed significant differences for all index tests based on pre-defined histological and non-invasive test stratification (Log Rank test p <0.05). At multivariate Cox regression analysis, ELF and liver histology were significant predictors of the primary outcome after adjusting for gender, diabetes, age and BMI. (ELF > 11.2 vs < 9.8 HR 132.7 [95%CI 15.6-1127.4 p<0.01], 9.8-11.2 vs <9.8 HR 22.5 [95%CI 2.8-184.3 p=0.04]) (F4 vs F≤2 HR 92.0 [95%CI 20.1-421.9 p<0.01], F3 vs F≤2 HR 10.2 [95%CI 2.3-45.5 p=0.05]). Furthermore, the intermediate and high risk group defined by LSM had a significantly higher risk of developing the composite outcome compared to the low-risk group (LSM 10-15kPa vs <10kPa HR 5.51 [95%CI 1.25 – 24.18 p=0.02], LSM >15kPa vs <15 kPa HR 22.89 [95%CI 6.17 – 84.94 p<0.01]). Intermediate risk group according to FIB4 displayed no significant higher risk of composite outcome compared to low-risk group (HR 2.87 [95%CI 0.53 – 15.55 p=0.22]).

Conclusion

The ELF test demonstrated comparable performance to histologically evaluated fibrosis in forecasting clinical outcomes. It should be regarded as a viable alternative to liver biopsy for conducting prognostic assessments in patients with MASLD.