Introduction

The enhanced recovery after surgery (ERAS) protocol is an evidence-based standardised multimodal programme formulated to reduce surgical stress and optimise recovery after surgery. The ERAS represents the best care practice for patients undergoing colorectal surgery. To ensure high compliance with active ERAS elements, patients must be educated to actively participate in the perioperative care pathway. ERAS protocols were originally designed to treat patients with CRC, only few studies have assessed this protocol in IBD patients.

Aims & Methods

The aim of this study was to investigate the adherence to ERAS in IBD patients. This retrospective study enrolled adult patients who underwent elective colorectal surgery and the ERAS protocol at our institute between May 2020 and December 2022. The patients were divided into IBD and non-IBD group. Data on medical history were collected from electronic health records.Preoperative, intraoperative, and postoperative data were collected for each procedure using a self-reported mobile application. Adherence was calculated for at least 75% of active ERAS items. Chi-square test was used to compare categorical variables.

Results

619 patients, 492 non-IBD and 127 IBD, were enrolled. The overall adherence to ERAS protocol items was similar between the two groups (84% vs 82%, p 0.2). Adherence was evaluated during the three ERAS phases in the groups: preoperative (92% vs 90%, p 0.11), hospitalization (63% vs 62%, p 0.8), post-discharge period (96% vs 93%, p 0.2). Moreover, focusing on the preoperative ERAS items adhrence, there were significant difference between non-IBD and IBD group in nutritional optimization (84% vs 67%, p <0.001) and smart communication (93% vs 89%, p 0.002). No difference were reported in the patient’s prehabilitation adherence (74 % vs 71%, p 0.4).

Conclusion

Introduction

Pancreatic neuroendocrine tumors (pNETs) are a heterogeneous group of tumors with different treatment options depending on pathological grading, clinical staging, and presence of symptoms related to hormonal secretion. Their classification is made on mitotic count and Ki-67 index.
The current standard for Grading assessment is analysing the material obtained from EUS-guided fine needle aspiration/biopsy (EUS-FNA/FNB). However this technique is not free from adverse events and could be challenging for NETs localization.
The evidence of high grade of fibrosis and microvascular density decrease (MVD) on tumor pathological specimens has led many authors to search for undirected malignant features of pNET extrapolated from non-invasive techniques. The introduction of ancillary techniques, such as second-generation contrast agents (CH-EUS), has improved study of pNET. Particularly, at CH-EUS examination contrast pattern well correlates with behaviour and grading of NETs. However, the use of contrast agents entails a prolongation of procedure time and additional costs. An innovative ultrasound Doppler technique, Detective Flow Imaging EUS (DFI-EUS), involves no additional time or cost as it doesn’t require the administration of contrast agent. There is still no standardisation of this technique and few studies have validated its use.

Aims & Methods

The aim of this study is to evaluate the DFI role in defining NET vascularization and its correlation with CH-EUS. The second aim of the study is to assess DFI role in predicting histological grading.
Single center retrospective analysis on consecutive patients with solid pancreatic lesions who underwent EUS at Therapeutic Digestive Endoscopy Unit of the Fondazione Policlinico Universitario Campus Bio-Medico in Rome.
After activation of DFI, each lesion was observed for at least 30 seconds. Lesions was classified into three grades, according to the degree of vascularisation at DFI: (grade 0 absence of microvascularization of the tumor; grade 1 minimal/isovascularization of the tumor; grade 2 markedly increased microvascularization).
All lesion with final hystological diagnosis of NET were enrolled.
Grading and Ki-67 index of tumors were reported.
Data about lesion’s features and procedure were collected.

Results

From April 2024 to February 2025, 17 patients were enrolled (58.8% male; mean age 57±12 years old). The majority of lesion (53%) were localized in the body of the pancreas and the mean lesion’ s size was 28±20 mm. The final histological diagnosis classified 50% lesions as G1, 38.8% G2 and 5.5% G3.
At the CEH-EUS the 70.6% of lesion showed hyper-enhancement. About the DFI evaluation the 17.6% of lesion was hypo-vascular, 17.6% Iso-vascular and 64.7% was hyper-vascular. There was excellent correlation between DFI characterization of the lesion and the CH-EUS (ICC 0.9)
Among the NET G1, 66.7% were Hypervascular at DFI and 33.3% Isovascular. Among the G2, 71.4% were Hypervascular at DFI and 28.6% Hypovascular. The only G3 lesion was Hypovascular.
There was inverse correlation between the NET grade and the DFI grade (Pearson coefficient -0.56; p 0.02).

Conclusion

DFI-EUS can provide a fast evaluation of the micro-vascularization of pNET with excellent correlation with CH-EUS. Hyper-vascular pattern at DFI correlates with low Ki-67 index.

Clinical Case Summary

We report the case of 20 year old female patient with Crohn's disease who was shifted to Combo therapy (Infliximab + Azathioprine) for failing to reach mucosal healing on Conventional treatment. Quantiferon test, virology panel and a CT chest were negative prior to therapy. After one year of treatment she presented with high grade fever, weight loss, and abdominal pain. COVID-19 PCR and CT chest were negative. However, quantiferon test was positive. CTE abdomen showed marked thickening and stricture in the ileocecal area. Colonoscopy (Video available) was done to obtain biopsies; serpiginous ulcers with narrowing were noted. Histopathological assessment showed heavy Inflammatory cells with no more specification. A gene Xpert PCR on the tissue biopsy was positive for MTB. Given the septic state of the patient biological therapy was held for the duration of her treatment. She started Anti-TB and improved as the fever subsided and she gained weight. Colonoscopy was re-attempted after 4 months of treatment to confirm resolution (Video available). An impassable fibrotic stricture was noted the biopsy forceps could however be introduced and biopsies were obtained. Gene Xpert test was negative. The patient was started on Ustekinumab monotherapy with good response.
TB infection in patients on Anti-TNF therapy is a well-recognized potential side-effect of these drugs. To the best of our knowledge, this is the first reported case of Ileocecal TB on top of Crohn’s disease. A major challenge was weighing how much of the active inflammation shown in the endoscopy, biopsy and imaging was due to TB infection and how much was because of Crohn's disease activity. The time to re-initiate therapy was difficult given that the patient's bad general condition before starting antimicrobial treatment. While recommendations suggest starting immunosuppressives after 8 weeks of treatment in active tuberculosis, the evidence support this in pulmonary rather than extrapulmonary tuberculosis.

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

Pancreatic Ductal Adenocarcinoma (PDAC) is a highly aggressive and lethal malignancy of the pancreas due to limited treatment response and lack of early diagnosis. PDAC accounts for more than 90% of all pancreatic neoplasms and early PDAC may be missed on Computed Tomography (CT) scan due to similar attenuation as healthy pancreas, small size and hidden location.

Aims & Methods

The current study aims at improving detection of PDAC with CT scans using a deep learning model. It uses three different Convolutional Neural Network (CNN) models namely, Visual Geometry Group 19 (VGG19), Residual Neural Network 50 (ResNet-50) and Inception-v3. A compendium of 129,910 abdomen CT images (107 patients) of PDAC patients and 18,942 abdomen CT images (80 patients) of healthy controls were considered from The Cancer Imaging Archive. Additionally, several pre-processing and image augmentation methods were used to prevent overfitting and improve accuracies.

Results

The current model showed high construct validity with markedly lowered computational power. The Inception-v3 model showed the highest accuracy in the detection of PDAC with an accuracy of 97.93%. Specificity of the VGG-19 model was the highest at 98.77 whereas sensitivity was the highest for the Inception-v3 model at 98.75%. Data on the CNN models’ Performance Metrics (accuracy, sensitivity, specificity and area under ROC) ​were all compared.

Conclusion

The deep learning enabled tool accurately detected PDAC on CT scans versus healthy controls. The models were also reasonably sensitive for tumours below 2 cm.

References

1. Ushio J, Kanno A, Ikeda E, et al. Pancreatic Ductal Adenocarcinoma: Epidemiology and Risk Factors. Diagnostics (Basel). 2021;11(3):562. doi:10.3390/diagnostics11030562
2. Qureshi TA, Gaddam S, Wachsman AM, et al. Predicting pancreatic ductal adenocarcinoma using artificial intelligence analysis of pre-diagnostic computed tomography images. Cancer Biomark. 2022;33(2):211-217. doi:10.3233/CBM-210273
3. Ahmed HS. BEYOND TRADITIONAL TOOLS: EXPLORING CONVOLUTIONAL NEURAL NETWORKS AS INNOVATIVE PROGNOSTIC MODELS IN PANCREATIC DUCTAL ADENOCARCINOMA. Arq Gastroenterol. 2024;61:e23107. doi:10.1590/S0004-2803.24612023-117