Introduction

The standard surgical treatment for rectal cancer is total mesorectal excision (TME), which may negatively affect patients’ functional outcomes and quality of life (QoL). However, it is unclear how different TME techniques may impact patients’ functional outcomes and QoL.

Aims & Methods

This systematic review and meta-analysis evaluated functional outcomes of urinary, sexual, and fecal functioning as well as QoL after open, laparoscopic (L-TME), robot-assisted (R-TME), and transanal total mesorectal excision (TaTME). A systematic review and meta-analysis, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statements, were conducted (PROSPERO: CRD42021240851). A literature review was performed (sources: PubMed, Medline, Embase, Scopus, Web of Science, and Cochrane Library databases; end-of-search date: September 1, 2023), and a quality assessment was performed using the Methodological index for non-randomized studies. A random-effects model was used to pool the data for the meta-analyses.

Results

Nineteen studies were included, reporting on 2495 patients (88 open TME, 1171 L-TME, 995 R-TME, and 241 TaTME). Quantitative analyses comparing L-TME vs. R-TME showed no significant differences regarding urinary and sexual functioning, except for urinary function at three months post-surgery, which favored R-TME (SMD [CI] -0.15 [-0.24 – -0.06], p=0.02; n=401). Qualitative analyses identified most studies did not find significant differences in urinary, sexual, and fecal functioning and QoL between different techniques.

Conclusion

This systematic review and meta-analysis suggests no significant differences in patients' urinary, sexual, and fecal functioning and their QoL between various TME techniques. However, further high-quality, randomized-controlled, and prospective cohort studies are needed to confirm these findings.

Introduction

High-resolution anoscopy (HRA) plays a central role in the detection and treatment of precursors of anal squamous cell carcinoma (ASCC). The visual characterization of high-grade intraepithelial lesions (HSIL) is hampered by a limited interobserver agreement. Artificial intelligence (AI) algorithms have shown high levels of efficiency in detecting and differentiating HSIL from low-grade squamous intraepithelial lesions (LSIL) in HRA images. Nevertheless, these studies have been conducted using a digital videoproctoscope, whose use is not predicted in the standards of the International Anal Neoplasia Society (IANS). Our aim was to develop a deep learning system for automatic detection and differentiation of HSIL versus LSIL using HRA images from both conventional and digital proctoscopes.

Aims & Methods

A convolutional neural network (CNN) was developed based on 151 HRA exams from 137 patients undergoing HRA at two large volume centres (GH Paris Saint-Joseph, Paris, France and Emílio Ribas Infecciology Institute, São Paulo, Brazil), using conventional HRA (KLP 200 LED®, Kolplast) and digital HRA (THD Proctostation®, THD SpA). A total of 58,498 images were included, 29,212 images containing HSIL and 29,286 LSIL. Partial subanalyses were performed to evaluate the performance of the CNN in the subset of images with no staining (n=2,820), acetic acid (n=27,191), lugol (n=10,011), and after treatment of the anal canal (n=11,047). For these subanalyses, training, and testing datasets comprised 90% and 10% of each class's total number of images. The sensitivity, specificity, accuracy, positive and negative predictive values, and area under the curve (AUC) were calculated.

Results

The overall accuracy of the CNN in distinguishing HSIL from LSIL during the testing stage was 98.6%. The algorithm had an overall sensitivity and specificity of 97.3% and 99.1%, respectively. The overall AUC was 0.99. For staining with acetic acid, HSIL was differentiated from LSIL with an overall accuracy of 96.4%, while for lugol and after therapeutic manipulation these values were 96.6% and 99.3%, respectively. The AUC ranged between 0.98 and 1.00 in these particular subgroups.

Conclusion

The introduction of AI algorithms to HRA may enhance the early diagnosis of ASCC precursors, and this system showed to perform adequately across conventional and digital HRA interfaces. Improving the detection of ASCC precursors may improve the treatment outcomes and prognosis. The developed AI model is the first model capable of performing adequately in different clinical sub settings and in different systems available on the market.

References

1. Hillman, R.J.; Cuming, T.; Darragh, T.et al. 2016 IANS International Guidelines for Practice Standards in the Detection of Anal Cancer Precursors. J Low Genit Tract Dis 2016; 20: 283-291.
2. Mistrangelo, M.; Salzano, A. Progression of LSIL to HSIL or SCC: is anoscopy and biopsy good enough? Tech Coloproctol 2019; 23: 303-304.
3. Deshmukh, A.A.; Suk, R.; Shiels, M.S.et al. Recent Trends in Squamous Cell Carcinoma of the Anus Incidence and Mortality in the United States, 2001-2015. J Natl Cancer Inst 2020; 112: 829-838.
4. Palefsky, J.M.; Lee, J.Y.; Jay, N.et al. Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer. New England Journal of Medicine 2022; 386: 2273-2282.
5. Neukam, K.; Milanés Guisado, Y.; Fontillón, M.et al. High-resolution anoscopy in HIV-infected men: Assessment of the learning curve and factors that improve the performance. Papillomavirus Res 2019; 7: 62-66.
6. Saraiva, M.M.; Spindler, L.; Fathallah, N.et al. Artificial intelligence and high-resolution anoscopy: automatic identification of anal squamous cell carcinoma precursors using a convolutional neural network. Tech Coloproctol 2022; 26: 893-900.
7. Pathologists, C.o.A. Protocol for the Examination of Excision Specimens From Patients With Carcinoma of the Anus. 2021; 4.2.0.

Introduction

Effective timing of endoscopic interventions and follow-ups is crucial in the management of severe acute pancreatitis. Implementing a multidisciplinary team (MDT) approach not only enhances this timing but also ensures consistent clinical care, providing rapid responses to complications and timely adjustments in treatment plans. This coordinated approach optimises recovery and improves patient outcomes by integrating timely diagnostics and interventions. The MDT’s strategic involvement is vital for maintaining high standards of care and safety and ensuring consistent and effective treatment of severe acute pancreatitis.

Aims & Methods

This retrospective cohort study assessed the impact of a novel hub-and-spoke severe acute pancreatitis (SAP) multidisciplinary team (MDT) model at a tertiary hepato-pancreato-biliary (HPB) centre. The model, which included Gastroenterologists, Surgeons, Nurses, Dieticians, and Radiologists, focused on optimising clinical outcomes by enhancing the coordination of hospital transfers and precision in the timing of interventional endoscopies. The study compared patient outcomes before the MDT implementation (January 2022 to January 2023) and after (November 2023 to March 2024), to improve intervention scheduling and establish systematic follow-up protocols to ensure comprehensive care. The primary objective was to evaluate how the MDT model influenced the timing of interventions and follow-up procedures in severe acute pancreatitis management.

Results

This study evaluated clinical outcomes for acute pancreatitis across two cohorts, comprising 191 patients before the implementation of a multidisciplinary team (MDT) and 76 patients following the implementation. For the pre-MDT cohort, the aetiology of pancreatitis included gallstone-induced cases (n=50), alcohol-related (n=45), idiopathic (n=2), and unspecified (n=94), with 28.79% of the cohort having a history of gallstones. In the pre-MDT group, the scheduling of interventions lacked consistency. 10 patients required inpatient endoscopic procedures, with a median time from admission to intervention of 13.0 days and a mean time of 12.79 days.
Post MDT implementation, 7 patients required inpatient endoscopic procedures, with waiting times reduced to a median of 6.5 days and a mean of 6.3 days. All these inpatients (n=7/7) received their procedures within the first week. The median duration of hospital stays was reduced from 8 days (pre-MDT) to 5 days (post-MDT). Additionally, the proportion of inpatients discharged within the first week post-intervention increased from 30% (n=3/10) pre-MDT to 71.4% (n=5/7) post-MDT. The average clinic follow-up time decreased from 169 days pre-MDT to 43 days post-MDT. The median timing to outpatient endoscopy was reduced, with 68% of patients receiving it in a six-week window post-discharge.

Conclusion

The integration of a multidisciplinary team (MDT) has markedly improved the management of severe acute pancreatitis, enhancing the precision and efficiency of interventional endoscopies. This optimised coordination has reduced hospital stays and ensured timely interventions, significantly boosting patient outcomes. The MDT approach effectively addresses the complexities of the condition, transforming patient care with tailored and rapid treatment strategies.

Disclosure

No disclosures

Introduction

Managing decompensated cirrhosis is a significant challenge due to high morbidity and mortality rates. The recently proposed Baveno VII criteria provide a standardized definition to assess recompensation. In this study, we validated the Baveno VII definition of recompensation and aimed to evaluate recompensation factors in patients with decompensated viral cirrhosis.

Aims & Methods

This is a retrospective descriptive study over a 10-year period between 2012 and 2022, enrolling 99 patients from the hepato-gastroenterology department of Mohamed Taher Maamouri Hospital in Nabeul who had been treated for decompensated viral cirrhosis B or C and achieved sustained virological response with a follow-up of at least 12 months.

Results

A total of 99 patients with decompensated viral cirrhosis (B or C), who had received treatment and achieved sustained virological response, were included in the study. The mean age was 62 ± 11 years, and 56 patients were female. The most common mode of decompensation was ascites, observed in 81.8% of the patients. The mean MELD score was 15 ± 4, and the majority (59.7%) were classified as Child-Pugh class B. Overall, 45.5% of the decompensated patients achieved recompensation during the study period. The recompensation rate was higher in patients with hepatitis B-related cirrhosis (51.1%) compared to those with hepatitis C-related cirrhosis (40.4%).
According to the results of logistic regression, four independent factors associated with recompensation were found: albumin ( OR = 2.033, IC95% [1,461-2,827], p<0.001 ), diabetes ( OR =0.003, IC95%[0.000-0.045], p<0.001 ), Child Pugh score ( OR=0.162, IC95% [0.057-0.459], p=0.001 ), INR ( OR =0.017, IC95%[0.000-0.939].

Conclusion

This study identified key factors associated with recompensation in patients with viral decompensated cirrhosis, including serum albumin levels, INR values, history of diabetes, and severity of liver disease. The knowledge of recompensated indicators may help support the development of different prevention strategies to reduce the incidence of acute decompensation.

Introduction

In the early phase of acute pancreatitis (AP), fluid resuscitation plays a crucial role. Changes in fluid distribution, increased capillary permeability, minimized intravascular volume, and loss of vascular resistance may lead to cardio-vascular and renal failure. On the other hand, overhydration is associated with cardiac decompensation and respiratory failure. Previously, intensive fluid therapy with large volumes of crystalloids was recommended without addressing individual needs for fluid therapy.
We used measurements of physiological parameters focusing on cardiac function and changes in body composition, to study the association between fluid therapy and physiological response, in the patient with AP.

Aims & Methods

This study aimed to assess fluid distribution in relation to fluid therapy, inflammation, and cardiac- and renal function in the early phase of AP.
This was a single-centre, prospective observational cohort study. On baseline, day 1, 2, 10 and 90 following were assessed: preload dependency (passive leg raise manoeuvre and defined as a >10% increase in stroke volume), hemodynamic parameters (stroke volume, cardiac output measured by non-invasive monitoring (Non-invasive LiDCOrapidTM; LiDCO, London, UK)), bioimpedance variables (weight, extracellular water (ECW), total body water(TBW) by seca mBCA 525, Germany). White blood count (WBC), C-reactive protein (CRP), and creatinine were measured and Modified Marshall score was calculated on each time point. Data are presented as medians with interquartil range (IQR). [jK1] Pearson correlation coefficient was used to assess the relationship between changes in weight and haemodynamic and bioimpedance parameters.

Results

Eighty-eight patients with first-time AP were included. Median age was 58 years, 46 were females. Gallstones were the predominant etiology (55%). At baseline, 35 patients (40%) were preload dependent. However, the median increase in weight during the first 10 days of admission was 2.65 kg (IQR: 0.9;4.73). Across time points, patients in the fourth upper quartile of weight increase had significantly higher volume of ECW than patients in the 1-3. quartile (p=0.02). No differences were observed for stroke volume, nor cardiac output. CRP was significantly higher in patients in the fourth upper quartile of weight increase than in patients in quartile 1-3. No difference was found for WBC and creatinine.
We found a significant correlation between increasing bodyweight and extracellular water volume, R=0.383, (p<0.0001), but not between increasing bodyweight and stroke volume R=-0.016 (p=0.783) or cardiac output, R=0.015 (p=0.796). Also, a significant correlation was found between creatinine and increasing weight, R=0.229 (p<0.0001). Modified Marshall score was significantly correlated to increasing body weight, R=0.159 (p=0.006).

Conclusion

The assessment of hydration status in AP requires an in-depth knowledge of body fluid homeostasis. Our data provide physiological rationale for emerging evidence regarding more restricitive fluid resuscitation. Personalized- and goal directed therapy may be a promising novel way in the transition from necessary fluid resuscitation to harmful fluid volume accumulation in the early phase of AP.

References

The Interplay between Inflammation, Coagulation and Endothelial Injury in the Early Phase of Acute Pancreatitis: Clinical Implications.
Dumnicka P, Maduzia D, Ceranowicz P, Olszanecki R, Drożdż R, Kuśnierz-Cabala B.
Int J Mol Sci. 2017 Feb 8;18(2):354. doi: 10.3390/ijms18020354.
Tenner S, Baillie J, DeWitt J, Vege SS;
American college of Gastroenterology guideline: management of acute pancreatitits
Am J Gastroenterol 2013; 108: 1400-16.27.
Working group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidencebased guidelines for the management of acute pancreatitis
Pancreatology 2013; 13:Suppl 2:e1-e15
Disturbances of the microcirculation in acute pancreatitis.
Cuthbertson CM, Christophi C.
Br J Surg. 2006 May;93(5):518-30. doi: 10.1002/bjs.5316.
Fluid Resuscitation in Acute Pancreatitis - Going over the WATERFALL.
Gardner TB
N Engl J Med. 2022 Sep 15;387(11):1038-1039. doi: 10.1056/NEJMe2209132.

Introduction

With the advent of EUS guided biliary interventions, there is a lot of hype created that ERCP will cease to be performed. The most important and limiting factor for ERCP is successful bile duct cannulation. We have studied a large series of our cases and tried to study the impact of properly performed precut on success of bile duct cannulation.

Aims & Methods

Aim: To analyze the efficacy of freehand precut for selective cannulation in difficult ERCP and its role in improving technical success rate, obviating need for EUS guided / other rendezvous techniques.
Methods: Retrospective analysis of 3000 patients undergoing ERCP from 2017 till date for varied etiologies. No. of patients required precut accessotomy were noted and technical success rate was measured.

Results

No. of patients analyzed- 3000. Selective biliary cannulation- 2452 (81.74%). Difficult cannulations requiring freehand precut accessotomy- 548 (18.26%). Technical success after precut achieving biliary access- 539 (98.36%). Failure of biliary cannulation even after precut- 09 (1.64%). Most common etiology in precut casesstone disease 360 (65.70%) followed by malignant lesions 118 (21.53%), benign strictures 28 (5.11%), post cholecystectomy biliary leak 28 (5.11%), post traumatic biliary leak 10 (1.82%), post hydatid surgery biliary leak 02 (0.36%), post central hepatectomy biliary leak 02 (0.36%). Most common cause for failure in precut cases was extensive edema and deformed anatomy. Of all failed cases 3 were large stones who were subjected to surgery and 6 were malignant lesions who were subjected to EUS guided biliary drainage.

Conclusion

Free hand precut technique, done correctly, is a savior in difficult cannulation cases and it increases the success rate of selective biliary cannulation significantly avoiding the need for other costlier techniques such as EUS guided / Rendezvous techniques.

References

Mariani A, Di Leo M, Giardullo N, Giussani A, Marini M, Buffoli F, Cipolletta L, Radaelli F, Ravelli P, Lombardi G, D'Onofrio V, Macchiarelli R,
Iiritano E, Le Grazie M, Pantaleo G, Testoni PA. Early precut sphincterotomy for difficult biliary access to reduce post-ERCP pancreatitis: a randomized trial. Endoscopy. 2016 Jun;48(6):530-5. doi: 10.1055/s-0042-102250. Epub 2016 Mar 18. PMID: 26990509.
Davee T, Garcia JA, Baron TH. Precut sphincterotomy for selective biliary duct cannulation during endoscopic retrograde cholangiopancreatography. Ann Gastroenterol. 2012;25(4):291-302. ​PMID: 24714256; PMCID: PMC3959408.

Introduction

Acute pancreatitis (AP) often has unpredictable and complicated clinical course. Numerous biochemical predictors may aid in the risk stratification of AP (including interleukin 6 (IL-6)), but none of them are accurate. YKL-40 is glycoprotein playing mayor role in inflammation and angiogenesis, with reported average serum concentrations of ≥ 190 ng/mL in inflammatory diseases. It has been shown that IL-6 stimulates the production of YKL-40 and, in reverse, YKL-40 (at least in some tissues) induces the production of IL-6.

Aims & Methods

The aim of our study is to assess whether combined concentrations of both YKL-40 and IL-6 could be more informative in risk stratification of developing more severe form of AP than concentrations of either biomarker alone.
We included 150 consecutive consenting adults with AP admitted to Sestre milosrdnice UHC, Zagreb (June 2020-June 2023). Patients with any acute/chronic diseases known to be associated with dysregulated expression of YKL-40 were excluded. Alongside routine laboratory studies (including C-reactive protein (CRP)), 7 mLs of blood were withdrawn for determining YKL-40 and IL-6 concentrations on admission and 48h after. Severity of disease was defined using revised Atlanta classification. Blood samples for YKL-40 and IL-6 quantification in 30 consenting non-AP adults consistent with previously mentioned exclusion criteria were withdrawn. They were matched 1:1 by age and sex to randomly selected 10 patients from each of AP severity categories. Analysis were performed using enzyme-linked immunosorbent assays. AP patients were classified into 2 categories for each biomarker (based on YKL-40 and IL-6 concentrations on admission and 48h after): 1. for YKL-40: low (<190 ng/mL) and high (≥190 ng/mL); 2. for IL-6: low (<42 pg/mL) and high (≥42 pg/mL). Cumulative multimodal logit models were fitted to ordinal outcome “AP severity” – using raw data, and data after entropy balancing undertaken to balance the two categories of YKL-40 and IL-6 concentrations on age, sex, time between symptom onset and admission, and CRP concentrations.

Results

The results showed lower YKL-40 (<50 ng/mL) and IL-6 (<20 pg/mL) concentrations in 30 non-AP adults compared to AP patients. At both time points (on admission and 48h after), odds of more severe AP were clearly higher with YKL-40 and IL-6 concentrations above vs. below the cut-off values (190 ng/mL and 42 pg/mL, respectively), and were particulary higher in patients with both cytokines above the cut-off vs. patients with both cytokines below the cut-off. The same relationship was maintained with adjustments for age, body mass index, days elapsed since symptom onset and admission, and for CRP concentrations – however, the strength of association was lower. This is in line with the fact that high CRP concentration predicts more strongly severe AP forms when taken 48h after compared to admission. This phenomenon was apparent also when the interaction term was included in the model: at CRP concentrations 45 mg/L, neither YKL-40, or IL-6 or their combination above the cut-off values were associated with the outcome; at CRP concentrations 90 mg/L, odds were higher, and were particularly high for a combination of high YKL-40 and high IL-6. The same was observed at CRP concentrations 180 mg/L.

Conclusion

Overall, data suggest that combined YKL-40 and IL-6 concentrations in acute AP, taken either on admission or 48h after, predict more strongly moderate and/or severe (vs. mild) AP than either cytokine alone, and do so 'on-top' of the CRP concentrations.

References

1. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG et al. Classification of acute pancreatitis - 2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102–111.
2. van den Berg FF, de Bruijn AC, van Santvoort HC, Issa Y, Boermeester MA. Early laboratory biomarkers for severity in acute pancreatitis; A systematic review and meta-analysis. Pancreatology. 2020;20(7):1302-1311.
3. Tizaoui K, Yang JW, Lee KH, Kim JH, Kim M, Yoon S et al. The role of YKL-40 in the pathogenesis of autoimmune diseases: a comprehensive review. Int J Biol Sci. 2022;18(9):3731-3746. doi: 10.7150/ijbs.67587.
4. Blazevic N, Rogic D, Pelajic S, Miler M, Glavcic G, Ratkajec V et al. YKL-40 as a biomarker in various inflammatory diseases: A review. Biochem Med. 2023;34(1):010502.