Introduction

Endoscopic Retrograde Cholangiopancreatography (ERCP) is pivotal in managing complex biliary strictures due to various causes like Cholangiocarcinoma (CCA), Primary Sclerosing Cholangitis (PSC), and mass-related intrahepatic strictures. Traditional ERCP relies on two-dimensional (2D) X-ray imaging, which often presents challenges in accurately localizing and selectively cannulating specific intrahepatic ducts. This study aims to assess the feasibility and effectiveness of three-dimensional (3D) fluoroscopic ERCP in diagnosing and treating complex biliary strictures.

Aims & Methods

We conducted a prospective pilot study, approved by the Institutional Review Board. Adult patients scheduled for ERCP for complex biliary strictures were enrolled. Exclusions included inability or unwillingness to consent, existing percutaneous biliary drainage, or unfeasible selective trans-papillary biliary cannulation.
Performance of 3D ERCP Patients were positioned on a 3D fluoroscopic table. ERCP followed standard protocols, with high-volume contrast injections opacifying bile ducts. After achieving full biliary tree opacification, a balloon was inflated in the distal bile duct in preparation for 3D imaging. To minimize radiation exposure to staff, the endoscope was fixed in a holder, and the room was evacuated before 3D image acquisition. These images were reconstructed to produce detailed 3D visuals of the target area, aiding real-time therapeutic maneuvers like selective intrahepatic duct cannulation.
Data Collection and Analysis Data included continuous variables (mean ± standard deviation) and categorical variables (percentages). Radiation exposure was quantified separately for ERCP and 3D reconstruction, using thermoluminescent dosimeters. Results were reported as Effective Surface Dose (ESD) in mGY and Dose Area Product in mGY.cm^2.

Results

Eighteen patients (median age 66.6) underwent 3D ERCP. 40% had a malignant biliary structure etiology, with 50% showing both intrahepatic and extrahepatic bile duct involvement. 3D reconstruction facilitated successful selective wire cannulation in 80% of cases, previously unachievable with conventional ERCP. One case provided crucial imaging for liver resection planning. The additional radiation dose was 16.44 mGY.cm².

Conclusion

This pilot study proves the feasibility of 3D ERCP in managing complex biliary strictures. This first-of-its-kind study highlights the utility of 3D reconstruction in ERCP. While significantly aiding selective intrahepatic duct cannulation and surgical planning for cholangiocarcinoma resections, it doubles the procedure's radiation exposure, potentially raising cancer risk to 1 in 1000. However the dose needed is significantly lower the IR guided biliary interventions.Further larger studies are required to evaluate the clinical efficacy of 3D ERCP.

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 incidence of pancreas cysts is increasing, and the use of EUS-guided through-the-needle-biopsy (EUS-TTNB) is gradually increasing for accurate diagnosis. However, studies including a large number of patients on clinical outcomes and safety of EUS-TTNB for pancreatic cysts are still lacking. In this study, we evaluated the diagnostic yield, adverse events(AE), and risk factors of AE related to EUS-TTNB in a large number of cohorts.

Aims & Methods

We reviewed the prospectively collected EUS-TTNB for pancreatic cysts database at Asan Medical Center, between January 2019 and December 2022. We analyzed technical success rate, diagnostic yield, AE, and risk factors for AE.

Results

A total of 248 patients were analyzed. Technical success could be achieved in 247 patients, except one patient (100%). Among them, 191 patients had a specific histologic diagnosis (diagnostic yield, 77.3%). There was no significant difference in diagnostic yield according to the number of biopsy specimen, the presence of septation in the cysts, the size of cysts, and location of cysts. AE occurred in 41 patients (16%), and there was no serious AE. Acute pancreatitis was the most common AE (12/248, 12%) following cyst hemorrhage (7/247, 3%). In univariate analysis on the risk factors of acute pancreatitis related to EUS-TTNB, male (HR 2.22, 95% CI: 1.02-4.83, P=0.045) and IPMN (HR 3.08, 95% CI: 1.35-7.03, P=0.01) were statistically significant. In multivariate analysis, IPMN (HR 2.75, 95% CI: 1.24-6.11, P=0.01) was the significant risk factor of acute pancreatitis after EUS-TTNB.

Risk factors of acute pancreatitis after TTNB

Conclusion

EUS-TTNB showed a relatively high technical success rate and diagnostic yield. IPMN was the most significant risk factor of AE related to EUS-TTNB.

References

The clinical relevance of the increasing incidence of intraductal papillary mucinous neoplasm, Clin Gastroenterol Hepatol. 2012 May;10(5):555-8
European evidence-based guidelines on pancreatic cystic neoplasms, Gut. 2018 May;67(5):789-804
International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas, Pancreatology 2012;12:183–197.
Diagnosis of pancreatic lesions collected by endoscopic ultrasound-guided fine-needle aspiration using next-generation sequencing, HPB (Oxford). 2015 May; 17(5): 377–386.
Suboptimal accuracy of carcinoembryonic antigen in differentiation of mucinous and nonmucinous pancreatic cysts: results of a large multicenter study, Gastrointest Endosc. 2015 Dec;82(6):1060-9
Efficacy and safety of EUS-guided through-the-needle microforceps biopsy sampling in categorizing the type of pancreatic cystic lesions, Gastrointest Endosc. 2022 Feb;95(2):299-309

Introduction

Inflammatory bowel diseases (IBD), encompassing ulcerative colitis (UC) and Crohn’s disease (CD), are associated with an increased risk of metabolic bone diseases (MBD), primarily osteopenia and osteoporosis; however, the risk at IBD diagnosis is currently unknown.

Aims & Methods

The aim of the current study was to evaluate a screening strategy for MBD in which all patients with newly diagnosed IBD are offered a Dual-energy X-ray absorptiometry (DXA) scan. Secondly, we aimed to identify risk factors for development of MBD.
All adult patients with newly diagnosed IBD within a catchment area corresponding to ~20% of the Danish population have since May 2021 been enrolled in an ongoing prospective population-based inception cohort, IBD Prognosis Study. Herein, all participants were, as part of the initial work-up, invited to a DXA scan at IBD diagnosis. A T-score< −2.5 standard deviations (SD) was diagnostic for osteoporosis, while a T-score between –1 and –2.5 defined osteopenia. Multivariate analyses adjusted findings for age, gender, and medication differences.

Results

As of April 15^th, 2023, a total of 316 newly diagnosed patients with IBD (UC: 178, CD: 117, IBD unclassified (IBDU): 21) received a DXA scan within 90 days (interquartile range (IQR) 51-139 days). Baseline characteristics of the population were similar to those previously described for newly diagnosed IBD.
In total, 48 (27.0%, females (F): 26.3%, males (M): 27.7%) and 17 (9.6%, F: 13.7%, M: 4.8%) patients with UC were found to have osteopenia and osteoporosis, respectively. The corresponding numbers for CD were 23 (19.7%, F: 15.3%, M: 24.1%) and nine (7.7%, F: 6.8%, M: 8.6%).
Subgroup analysis showed a high occurrence of osteopenia in both UC and CD regardless of age group (Table 1). Further, no difference between UC and CD was observed in terms of the risk of osteopenia (adjusted odds ratio (aOR)=1.86 (95% confidence interval (CI) 0.99-3.60) or osteoporosis (OR=1.42 (95% CI 0.53-4.08)).
Further, low albumin level (<36 g/L) was the only factor associated with the risk of osteopenia in patients with UC (aOR=2.57 (95% CI 1.05-6.53). In patients with CD, no risk factors were identified for development of osteopenia, although a trend was seen with high age (aOR=4.28 (95% CI 0.99-20.23). However, the risk of osteoporosis was independently associated with age higher than 65 years in both UC (aOR=13.4 (95% CI 3.78-51.36)) and CD (aOR=6.39 (95% CI 1.09-35.47)), while female gender was not relevant (UC: aOR=2.63 (95% CI 0.75-10.98), CD: (aOR=0.47 (95% CI 0.08-2.20)).
Finally, in both UC and CD, the risk of these MBD was not associated with IBD phenotype, medications, or patient-reported or endoscopic severity.

Table 2: Prevalence of osteopenia and osteoporosis in different age groups in patients with newly diagnoses patients with inflammatory bowel diseases

Conclusion

To our knowledge, the current study is the first evaluation of DXA scans as a screening tool for patients with newly diagnosed IBD in a population-based setting. We found a high incidence of osteopenia affecting every fourth patient at IBD diagnosis. These findings are concerning given the high risk of repeated need for systemic steroids in this patient population.

Disclosure

Mohamed Attauabi: None
Gorm Roager Madsen: None
Flemming Bendtsen: Tillotts, Ferring
Klaus Theede: Ferring, Janssen, Takeda, Pfizer and Tillotts
Jakob Benedict Seidelin: has received research grants from Takeda, Janssen, the Danish Research Council, and the Capital Region Denmark, and is national coordinator of studies from AbbVie, Arena Pharmaceuticals, Ely Lilly, and Boehringer Ingelheim.
Johan Burisch: reports grants and personal fees from AbbVie, grants and personal fees from Janssen-Cilag, personal fees from Celgene, grants and personal fees from MSD, personal fees from Pfizer, grants and personal fees from Takeda, grants and personal fees from Tillots Pharma, personal fees from Samsung Bioepis, grants and personal fees from Bristol Myers Squibb, grants from Novo Nordisk, personal fees from Pharmacosmos, personal fees from Ferring, personal fees from Galapagos, outside the submitted work.

Introduction

There are several preoperative localization methods for laparoscopic colorectal surgery. ICG (indocyanine green) injection has recently been in the limelight for preoperative localization. However, although the incidence is low, ICG injections may cause complications due to allergic reactions. In this study, we tried to check the feasibility and safety of autologous blood tattooing as an alternative to ICG.

Aims & Methods

From august in 2017 to July 2023, a total of 42 patients were preoperative endoscopic localization. Through preoperative endoscopy, 33 patients underwent autologous blood tattooing and 9 patients underwent ICG tattooing. The surgeon checked visibility and other complication such as abscess or spillage at the start of surgery. The characteristics of patients, outcomes, and complications were collected retrospectively.

Results

Patients characteristics showed no significant difference between the two groups. As for the location of localization, sigmoid colon was the most common in both groups. The two groups each had one imprecise localization. In autologous blood tattooing patient, the omentum interfered with detection, and in ICG tattooing patient, blurring was severe. In addition, in patients with autologous blood tattooing, detection was not possible in 2 patients due to adhesion and technical failure. In the case of complications, there was only one spillage in the ICG group, which resulted in blurring.

Conclusion

Preoperative autologous blood tattooing is a simple and useful technique because it has high visibility, and no complication. This method has the advantage that it does not require additional agents or facilities and can be performed quickly and accurately through the patient's blood. However, unlike ICG tatooing, there is a disadvantage that it is difficult to secure a field of view when there is an obstruction structure such as an omentum. In the future, further study of large size will be needed.