Clinical Case Summary

Superior mesenteric artery (SMA) syndrome is a rare cause of upper gastrointestinal obstruion.Nutcracker syndrome occurs as the result of external compression of the left renal vein. Although they share a similar pathophysilogy,occurring simultaneously is rare.
Case report 1: 41 years old female presented with chronic postprandial upper abdominal pain, frequent vomiting and marked weight loss.Barium meal showed thickened gastric and duodenal mucosa.Post contrast triphasic CT abdomen followed by 3D CT angiography revealed: dilated stomach, decreased aorta- SMA distance 5.5 mm& decreased aorta – SMA angle 20 degrees, compressed dilated left renal vein between aorta and SMA. She started conservative treatment with dietitian to gain more weight which relieved the pain and decreased vomiting episodes.
Case report 2: 16 years old female presented with persistant vomiting.Upper endoscopy showed dilated stomach with superficial erosions. CT aortic angiography revealed: reduced aorto mesentric angle to 19.8 and aorto mesentric distance reduced to 3.5 cm, proximal dilatation of the stomach, compression of left renal vein between aorta and SMA as well as mild dilated tortous ovarian and pelvic veins.Conservative treatment failed at first and due to refusal of surgery, she was sent for nasojejunal tube to optimize nutrition.
Case report 3: 36 years female patient presented with acute onset abdominal pain, vomiting with history of marked weight loss due to abdominal pain with attacks of hematuria. Barium meal and endoscopy suggested superior mesentric artery syndrome. CT angiography of the abdomen was ordered and showed decreased aorto mesentric angle to 16 and aorto mesentric distance to 2.8 cm, as well as compression of left renal vein between aorta and SMA suggesting SMA syndrome and nutcracker syndrome. Patient refused conservative treatment and refered for gastrojejunostomy and stent placement in the left renal vein for relief of obstruction of nutcracker syndrome.

Introduction

The effectiveness of H. pylori treatment decreases as eradication failures accumulate; however, bismuth quadruple therapy with the single-capsule has shown optimal results not only in first but also in second and subsequent lines of treatment, even in patients with dual clarithromycin and metronidazole resistant strains.

Aims & Methods

To evaluate the use and effectiveness of the single-capsule bismuth quadruple therapy when empirically prescribed as retreatment, despite one or multiple previous eradication failures with the same treatment.
All patients registered at e-CRF AEG-REDCap as part of the European Registry on H. pylori management (Hp-EuReg) from 2013 to 2023, who had received single-capsule therapy in at least 2 different treatment lines (not necessarily consecutive), were analyzed.

Results

Out of 2,579 patients treated with the single-capsule from 2^nd to 6^th rescue treatment line, 101 cases received again the same single-capsule therapy at least in 2 different treatment lines: 67 re-treatments in 2^nd line having previously failed in 1^st line with the single-capsule; 16 re-treatments in 3^rd line (of which 12 had previously received this same therapy in 2^nd line); 11 in 4^th line (previously having failed the same therapy in either 1^st , 2^nd or 3^rd line); 4 in 5^th line; and further 3 in 6^th line (Table). The effectiveness of bismuth quadruple therapy as single-capsule when empirically prescribed repeatedly in 2^nd line was over 90%, and achieved almost 80% in all cases retreated in 3^rd line.

Conclusion

The empirical administration of bismuth quadruple therapy as single-capsule when prescribed as re-treatment in 2^nd line after previous failure with the same therapy achieves optimal effectiveness (>90%).

Disclosure

Javier P. Gisbert has served as speaker, consultant, and advisory member for or has received research funding from: Mayoly, Allergan/Abbvie, Diasorin, Richen, Juvisé and Biocodex.
Olga P. Nyssen received research funding from: Mayoly, Allergan/Abbvie, Richen, Juvisé and Biocodex.

Introduction

There are doubts about the effectiveness of concomitant use of probiotics (PB) in the treatment of Helicobacter pylori infection. Objective: To determine whether the use of PB improves the effectiveness of eradication treatments used in Europe.

Aims & Methods

Prospective, multicentre, non-interventional, prospective registry (Hp-EuReg) of the clinical practice of European gastroenterologists. Data were collected in an e-CRD in AEG-REDCap from 2013 to 2021. All data from countries with at least 30 cases undergoing eradication therapy and at least 1 with associated PB were included, using patients without PB as controls and grouping by geographical region. Modified intention-to-treat (mITT) analyses were performed, as well as multivariate analysis, assessing factors associated with treatment effectiveness.

Results

36,699 patients were included, 8,233 (22%) with PB. Overall, PB use was associated with greater effectiveness (91% vs 86%; p<0.0001). Adjusting for treatment regimen, this significance held for triple (89% vs 83%; p<0.0001), concomitant quadruple (93% vs 89%; p=0.0009), quadruple with bismuth (92% vs 86%; p<0.0001) and sequential (91% vs 78%; p<0.0001) therapies. In the logistic regression model in first-line eradication (adjusted for age, sex, duration of eradication treatment, PPI dose and adherence), PB use maintained the benefit in the triple, bismuth quadruple and sequential treatments. After adjusting such a model by region, significance was maintained in the Eastern region (low rate of resistance to clarithromycin and metronidazole) for triple therapies, and in the Central region (high rate of resistance) for concomitant quadruple and sequential therapies.

Conclusion

In Europe, the use of formulations with PB adjuvant to eradication therapy is associated with increased effectiveness of eradication therapy, with the benefit being superior in triple and sequential therapies.

Disclosure

Nothing to disclosure

Introduction

EUS is a relatively new diagnostic technique, for which enormous improvements have been made. Recently, EUS was developed into a minimally invasive technique and applied in the diagnosis of pancreatobiliary diseases. However, improvements in the conventional training pattern of EUS are needed urgently.

Aims & Methods

in this study, we compared the results achieved after use of clinical practice training patterns combined with or without simulator training and evaluated the effectiveness of simulator use in EUS training.
The trainees were randomly divided into two groups: the experimental group was trained with both clinical practice and simulator training system and the control group was only trained through clinical practice. After 1 month of training, trainees of both groups were tested with an established technical evaluation procedure that aimed to assess trainees’ ability to examine the normal anatomical structure. Then, trainees in the experimental group completed a questionnaire.

Results

In our research study, we first divided the 18 trainees into two groups: experienced group and inexperienced group based on their endoscopic skills. Then, trainees from each group were randomly assigned to the experimental group and the control group. There were no statistically significant differences between the experimental and control groups in terms of gender, age, or endoscopic skills of trainees [P > 0.05]. After completing the training program, the trainees were tested with an established assessment procedure, which included a written test. The mean test score of trainees in the experimental group (64.53 ± 4.91) was significantly greater than that of the control group (60.09 ± 5.49; P = 0.028).
We performed Pearson correlation analysis to determine the correlation between the test score of individuals in the experimental group and the frequency of simulator use. The Pearson's correlation coefficient was calculated to be 0.097, which indicates that the individual test score may be positively correlated with the frequency of simulator use in the experimental group.
Finally, all the trainees of the experimental group were asked to finish a questionnaire survey about the simulator training program. All trainees gave positive feedback to questions pertaining to the reasonability of the simulator, the complexity of operative skills, and the operative similarity between the simulator and EUS. Moreover, the self-confidence of trainees was enhanced for EUS operation. Compared to the pretraining scores in the experimental group, the trainees’ self-confidence had improved significantly in the overall mean score after completing the training (6.93–7.67, P = 0.405)

Conclusion

Our study confirmed that use of a simulator can promote the effectiveness of a EUS training program. Trainees who were taught to operate on a simulator showed better operative skills while performing EUS in clinical practice. Moreover, after use of a simulator, their self-confidence also increased. Trainees were able to successfully identify the anatomical structures of the pancreatobiliary system, which were revealed by ultrasonoscopy. Moreover, our research study provides some valuable experience and constructive instructions that need to be included in the standardized EUS training program. In our future work, we hope to design a more comprehensive training procedure to improve the effectiveness of our EUS training program.

Clinical Case Summary

In pancreaticobiliary cancer, which has a poor prognosis, early recurrence often occurs even after curative resection. Recurrence around major blood vessels is also common, and it is possible that micro-cancer cells may remain around major vessels even after resection is achieved. Therefore, novel therapeutic strategy are needed to improve prognosis and achieve long-term survival. In this situation, high-intensity focused ultrasound (HIFU), a new non-invasive treatment, is expected to be used not only as neoadjuvant therapy but also as adjuvant therapy.
A 59-year-old woman underwent pancreaticoduodenectomy and cholecystectomy for ampullary carcinoma in May 2022. After that, in April 2023 during postoperative adjuvant chemotherapy, left supraclavicular lymph node metastasis was suspected, and chemotherapy was continued. A PET-CT scan in January 2024 showed local recurrence around the SMA to the aorta, and GEM+CDDP+Durvalumab therapy was administered as systemic chemotherapy from February 2024. After 6 courses, PET-CT and CT showed a reduction in the size of the tumor. Aiming for a negative surgical margin, HIFU therapy was performed in September 2024 as a local treatment at the site of local recurrence (7 cm) from around the SMA to around the aorta, the superior mesenteric vein, and the posterior side of the renal vein. One week later, tumor resection was performed. Although the pathological findings showed a negative margin, chemotherapy was performed as a postoperative adjuvant therapy. After that, the tumor marker was again elevated, so HIFU was performed again in December 2024 as an adjuvant therapy on the soft tissue at the resection site. The tumor marker decreased, and the patient is currently under observation.
In conclusion, surgical resection and multidisciplinary treatment with chemotherapy and HIFU therapy seem to be promising treatments for pancreaticobiliary cancer with poor prognosis to improve the prognosis and achieve long-term survival.

References

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Disclosure

none

Introduction

Cystic pancreatic tumors are rare tumours that are increasingly being discovered incidentally due in part to the improved performance of pancreatic imaging modalities (ultrasound, multidetector CT scan, MRI) and advancements in knowledge regarding the characteristics of these lesions. They are represented by serous cystadenomas (SC), mucinous cystadenomas (MC), intraductal papillary mucinous neoplasms (IPMN), and solid pseudopapillary tumors of the pancreas (SPTP). The aim is to study the epidemiological, clinical, biological, and etiological aspects of these pancreatic tumors.

Aims & Methods

This single-centre study was carried out from September 2015 to August 2023 and included all patients with cystic tumours of the pancreas. False pancreatic cysts were excluded from the study. Epidemiological, clinical, biological and echo-endoscopic data were collected from endoscopic-ultrasounds registers. All endoscopic-ultrasounds were performed under Propofol sedation using a Pentax-type radial and/or linear video echo-endoscope, and cytoponctions were performed using 19 G echotip needles for biochemical analysis of the cystic fluid and/or anatomopathological study.

Results

Out of a total of 649 biliopancreatic endoscopic ultrasounds performed, 53 patients were included, representing a prevalence of 8.16%. The mean age was 62.3 years (29-82 years) with a clear female predominance (Sex Ratio = 0.65). Discovery circumstances were incidental findings in 21 cases (39%), epigastric pain in 17 cases (32%), acute pancreatitis in 6 cases (11.3%), jaundice in 6 cases (11.3%), and abdominal pain in 3 cases (5.6%). Biochemically, cholestasis was found in 12 cases (22.6%), cytolysis in 5 cases (9.4%), and elevated Ca19-9 in 6 cases (11.3%). Endoscopic ultrasound revealed the location, number, and size of the tumor: 21 cases (39.6%) were located in the pancreatic head, 13 cases (24.5%) in the body, 9 cases (17%) in the tail, and 10 cases (18.9%) were multifocal, with an average tumor size of 28.5 mm (1.9-76 mm). Communication with pancreatic ducts was observed in 35 cases (66%), and Wirsung duct dilation in 16 cases (30.1%). Cytology was performed in 27 cases (51%). The endoscopic ultrasound appearance combined with cystic fluid analysis favored IPMN in 42 cases (79.2%), mucinous cystadenoma in 5 cases (9.4%), serous cystadenoma in 3 cases (5.7%), and SPTP in 3 cases (5.7%).

Conclusion

Cystic pancreatic tumors are rare neoplasms predominantly affecting women in their sixties, often discovered incidentally. They predominantly occur in the pancreatic head and are mainly comprised of IPMN followed by mucinous cystadenomas, with serous cystadenomas and SPTPs being less common.

Disclosure

no links of interest