Introduction

Pre-cut sphincterotomy are most often used as a salvage procedure after failure of conventional methods of bile duct cannulation although its success is not guaranteed.　
When we performed initial pre-cut sphincterotomy, papilla is incited, with needle knife or sphincterotome, until the opening of bile duct is recognized to gain access to its lumen.
Our technique, in cases of not recognized the opening of bile duct, involves engaging the exposing underlying submucosal tissue layer of the papilla with the catheter and then seeking bile duct with the hydrophilic guide wire, completely dependent on fluoroscopic view.
The purpose of this study was to assess the efficacy and safety of our technique in cases of failed pre-cut.

Aims & Methods

We retrospectively analyzed the clinical records of consecutive patients undergoing ERCP between 1 January 2009 and 31 October 2024 at Mitsui Memorial Hospital, Tokyo, Japan.
Patients who underwent an ERCP plus pre-cut were included.
Patients were divided into two groups, in whom the common bile duct could be cannulated (Group A), and the common bile duct could not be cannulated and our technique was performed(Group B), after initial pre-cut.
The primary objective was a successful biliary cannulation, and the secondary objective was the complication in group B.
The complications and patient characteristics were compared between group A and B using Fisher’s exact test.

Results

Over a period of fourteen years ten months, 262 Pre-cut sphincterotomy (Needle knife sphincterotomy 108, Transpancreatic septotomy 126, Both 28) were performed. After initial pre-cut, we could achieve biliary access in 183 (Group A), and could not in 79. We performed our technique in 77 among these 79(group B).
In Group B, the therapeutic indications for ERCP were choledocholithiasis in 44 (57.1%) of cases, malignant and benign biliary obstruction in 29(37.7%) and 4(5.2%). The average age of the patients was 73 years (range 29-96) and 45 (58.4%) were male. Among 77 patients, a successful biliary cannulation was achieved in 72 (93.5 %). Complications were 15(19.5%). 2 patients presented bleeding (2.6 %) and required endoscopic treatment and transfusion of red blood cells. 9 (11.7 %) patients developed post-ERCP pancreatitis (1 severe, 8 mild pancreatitis). Guidewire related perforations that were resolved with conservative management occurred in 4(5.2%).
Alerted anatomy status was more frequently observed in group B than group A (p < 0.01). The other characteristics of both groups were similar. Total complications were more frequently observed in group B (p ＝ 0.03).

Conclusion

Our technique in cases of failed pre-cut sphincterotomy is found to be highly effective method to get biliary access, but carried a higher adverse event rate.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a widely utilized procedure for managing biliary and pancreatic disorders (1). ERCP is associated with complications, and potential factors influencing the ERCP outcomes is a critical area of research (2). Among these factors, obesity has emerged as a variable of interest due to its increasing prevalence globally and its known associations with a range of health conditions (3). Previous studies have yielded conflicting results on the influence of obesity on ERCP outcomes, with some reporting higher complication rates, while others found no significant associations (4, 5). The interplay between weight and procedural outcomes across a spectrum of BMI categories remains underexplored. This study aimed to assess the impact of body mass index (BMI) on clinical aspects and procedural outcomes of ERCP.

Aims & Methods

A total of 2143 patients who underwent ERCP at Hitit University Hospital between January 2020 and February 2024 were initially included. Of these, 1315 patients were excluded due to incomplete clinical information, previous ERCP history, altered anatomy and pregnancy, resulting in a final cohort of 828 patients for analysis.
The included patients were stratified into BMI categories: ≤30 kg/m² and >30 kg/m². Additionally, subgroup analyses were performed across finer BMI classifications: ≤20, 20 to ≤25, 25 to ≤30, 30 to ≤35, and >35 kg/m². Clinical and procedural parameters evaluated included admission diagnoses of acute pancreatitis and acute cholangitis (according to Tokyo cholangitis grade), American Society of Anesthesiologists (ASA) scores, gender, history of cholecystectomy, cannulation success, cannulation time, post-ERCP complications including post-ERCP pancreatitis and other complications according to modified Cotton criteria and 30-day readmission rates. The relationships between BMI and the clinical aspects as well as procedural outcomes of ERCP were investigated.

Results

The study cohort consisted of 828 patients, with 75.8% (n=628) having a BMI ≤30 kg/m² and 24.2% (n=200) having a BMI >30 kg/m². Within the finer BMI categories, 3.7% (n=31) of patients had a BMI ≤20 kg/m², 24.2% (n=200) were in the 20 to ≤25 kg/m² range, 47.9% (n=397) were in the 25 to ≤30 kg/m² range, 19.7% (n=163) were in the 30 to ≤35 kg/m² range, and 4.5% (n=37) had a BMI >35 kg/m². The majority of patients (47.9%) were within the BMI range of 25–30 kg/m², reflecting a significant proportion of overweight individuals in the cohort. Patients with a BMI >35 kg/m² constituted the smallest group, accounting for only 4.5% of the total population.
The study found no statistically significant differences between the groups concerning admission rates for acute pancreatitis and acute cholangitis, ASA scores, cannulation success, post-ERCP complications, and readmission within 30 days after the procedure (p>0.05). Notably, women were found to be significantly more obese (p<0.001), and a higher weight was associated with an increased history of cholecystectomy (p=0.013).
Additionally, there were no significant differences in average age, Charlson comorbidity index, cannulation time, length of hospital stay, or white blood cell count at admission between the BMI groups (p>0.05). However, CRP and total bilirubin levels were significantly higher in the non-obese group compared to the obese group (p=0.01 and p=0.011, respectively).

Conclusion

BMI did not influence the incidence of acute pancreatitis or acute cholangitis on admission, ASA scores, cannulation success or time, post-ERCP complications, length of hospital stays, or 30-day readmission rates. Interestingly, higher CRP and total bilirubin levels were observed in patients without obesity at admission, warranting further investigation into their clinical implications.

References

1. Tokmak S TS. History of ERCP. The Turkish Journal of Academic Gastroenterology 2021;20: 1-2.
2. Duzenli T, Koseoglu H. Endoscopic Retrograde Cholangiopancreatography During the COVID-19 Pandemic: Effects of Enhanced Personal Protective Equipment. Dig Dis Sci 2021;66: 1845-1851.
3. Alfaris N, Alqahtani AM, Alamuddin N, Rigas G. Global Impact of Obesity. Gastroenterol Clin North Am2023;52: 277-293.
4. Deenadayalu VP, Blaut U, Watkins JL, Barnett J, Freeman M, Geenen J, et al. Does obesity confer an increased risk and/or more severe course of post-ERCP pancreatitis?: a retrospective, multicenter study. J Clin Gastroenterol2008;42: 1103-1109.
5. Fujisawa T, Kagawa K, Hisatomi K, Kubota K, Sato H, Nakajima A, et al. Obesity with abundant subcutaneous adipose tissue increases the risk of post-ERCP pancreatitis. J Gastroenterol 2016;51: 931-938.

Introduction

Abdominal pain is a common symptom in clinical settings, but its prevalence and impact on individuals in the global population are poorly understood.

Aims & Methods

We aimed to use the population-based Rome Foundation Global Epidemiology Study (RFGES)¹ dataset to assess the prevalence and burden of abdominal pain in the global population. Data from all 54127 individuals in 26 countries covering 6 world regions (Asia, Middle East, Eastern Europe, Western Europe, North America, and Latin America) surveyed via the Internet (49.1% females; mean age 43.7 years, range 18-97) were included in the analyses. The survey included the Rome IV diagnostic questionnaire, the PROMIS Global-10 quality of life (QoL) questionnaire, the Patient Health Questionnaire PHQ-4 (anxiety and depression), and questions about medical history and healthcare utilization. Survey respondents who reported pain anywhere in the abdomen in the past 3 months were classified as abdominal pain cases, and all others as controls.

Results

Abdominal pain was reported by 51.9% (95% CI: 51.4, 52.3) of people in the global sample. The prevalence was higher among women than men [59.6% (59.0, 60.1) vs. 44.4% (43.8, 45.0)], and declined across age groups: 60.5% (59.8, 61.2) for ages 18 to 34, 54.6% (53.8, 55.4) for ages 35 to 49 years, 45.5% (44.6, 46.4) for 50-64 years, and 37.7% (36.7, 38.7) for 65+ years. Abdominal pain prevalence varied markedly between world regions, from a low of 41.2% (40.2, 42.2) in Asia to a high of 66.5% (65.3, 67.7) in Eastern Europe. Among the 26 individual countries, it ranged from 32.1% (30.2, 33.9) in Japan to 69.3% (67.2, 71.3) in Egypt.
Individuals with abdominal pain were twice as likely as controls to meet criteria for one or more of the 22 disorders of brain-gut interaction (DGBI) assessed [54.2% (53.6, 54.8) vs. 25.0% (24.5, 25.5)] and more than twice as likely to report a history of organic gastrointestinal disorders: [9.8% (9.4, 10.1) vs. 4.2% (3.9, 4.4)]; p<0.0001 for both. However, 38.9% of people with abdominal pain neither met DGBI criteria nor had organic GI disease history.
People with abdominal pain had significantly lower physical and mental quality of life scores than controls, showed more impairment in work productivity and life activities, were more likely to have ever visited a doctor because of a bowel problem, and more likely to visit doctors frequently (at least monthly) for any health reasons. They also more commonly reported being concerned about their bowel functioning. For details see Table 1.

Conclusion

Abdominal pain affects half the adult global population, including many people who have no GI disorders. It is more common in women, younger individuals, and people in non-Asian countries. Having abdominal pain is associated with poorer quality of life, impaired work and life functioning, increased psychological symptoms and greater healthcare utilization. These findings underscore that abdominal pain, as a symptom rather than only as a part of diagnosed disorders, warrants attention by healthcare services and researchers to better address unmet needs of sufferers.

References

1. Sperber et al. Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study. Gastroenterology. 2021 Jan;160(1):99-114.e3. doi: 10.1053/j.gastro.2020.04.014.

Disclosure

BBDF, CA and RL are currently employees of Opella, a Sanofi company and may hold shares or stock options in the company. OSP receives licensing fees from MetaMe Health. MS has received unrestricted research grants from BioGaia; served as consultant/advisory board member for Biocodex, Tillotts, BioGaia, Renapharma, and AlfaSigma; and served on speakers' bureau for Tillotts, Takeda, Biocodex, Sanofi, Abbvie, Janssen Immunology, Pfizer, BioGaia, Renapharma, Mayoly and Bromatech. JT has given scientific advice to Aclipse, Adare, AlfaSigma, Bio-Codex, Clasado, Danone, Falk, FitForMe, Ironwood, Kyowa Kirin, Menarini, Promed, Ricordati, Takeda, Tsumura and Truvion Pharmaceuticals; received research support from Biohit, Kiowa Kirin, ProMed, Sofar, Takeda and Tsumura; and served on the speaker bureau for Abbott, Bio-Codex, Mayoly, Menarini, ProMed, Reckitt-Benckiser, Schwabe, Takeda, Thai Meiji and Truvion Pharmaceuticals. JH, DAD, ADS and SIB have no conflicts of interest to declare.

Introduction

Among immune-related adverse events (irAEs) caused by immune checkpoint inhibitors (ICIs), gastrointestinal irAEs (GI-irAEs) are relatively rare, and their risk factors and prognostic implications remain unclear.

Aims & Methods

We retrospectively analyzed 1,104 patients who initiated ICI therapy at our institution between January 2016 and December 2022 and for whom survival data were available. GI-irAEs were defined as colitis with an increase of ≥3 bowel movements/day from baseline in the absence of other causes, or symptomatic gastritis confirmed histologically. Risk factors and prognostic impact of GI-irAEs were evaluated.

Results

The median duration of ICI therapy was 107 days. The cohort included 754 males (68%) with a median age of 69 years. The primary tumor types were lung cancer (32%), gastrointestinal cancers (19%), urothelial carcinoma (13%), head and neck cancer (13%), and melanoma (11%). The overall response rate was 27.8%, and the disease control rate was 49.0%. irAEs of any grade occurred in 310 patients (28%), and GI-irAEs were observed in 30 patients (2.7%). In univariate logistic regression analysis, use of anti-CTLA-4 antibody, combination ICI therapy, a prognostic nutritional index (PNI) ≥ 40, and platelet-to-lymphocyte ratio (PLR) ≥ 1.8 were associated with an increased risk of GI-irAEs. In multivariate analysis, only anti-CTLA-4 antibody use remained a significant risk factor (odds ratio: 9.2; 95% CI: 1.9–45). Kaplan–Meier analysis revealed that patients with GI-irAEs had significantly longer overall survival (OS) compared to those without irAEs in the overall cohort (median OS: 22.9 vs. 12.6 months, P < 0.0001). However, this difference was not observed in landmark analyses at 4 and 8 weeks post-treatment. Subgroup analysis based on PNI showed that in patients with PNI ≥ 40, those with GI-irAEs had significantly longer OS than those without irAEs (median not reached vs. 19.3 months, P = 0.0003). In contrast, in patients with PNI < 40, GI-irAE cases tended to have shorter OS than non-irAE cases (8.2 vs. 9.3 months). This trend was consistent in landmark analyses at 4 and 8 weeks.

Conclusion

The impact of GI-irAEs on prognosis appears to differ depending on the patient’s nutritional status. Particular caution is warranted for patients in poor general condition receiving ICIs, especially those involving anti-CTLA-4 antibodies, as GI-irAEs may serve as a poor prognostic factor in this population.

Introduction

Women have been historically underrepresented in gastrointestinal endoscopy research. Understanding the current patterns of female authorship is essential to assess progress and identify persistent gaps within this field.

Aims & Methods

This study aimed to evaluate the representation of women as first and senior (last) authors the three highest-impact journals in gastrointestinal endoscopy (Endoscopy, Gastrointestinal Endoscopy and Digestive Endoscopy) from 2015 to 2024. For each publication, we extracted bibliometric data of original articles, review articles and editorials, including the names of the first and senior authors, their primary country of affiliation, and the year of publication. Countries and territories were categorized by geographic region. Author gender was predicted using Genderize.io software (https://genderize.io), and only authors with ≥80% gender prediction accuracy were included.

Results

We analyzed 4,414 publications. Among first authors, 885 (20.15%) were women from 36 countries and 3,507 (79.85%) were men from 49 countries. Most female first authors were affiliated with institutions in North America (36.61%), while most male first authors were based in Asia (40.82%). The greatest gender disparity among first authors was observed in Asia (male-to-female ratio = 6.8), and the lowest in Europe (male-to-female ratio = 2.5). Among senior authors, 433 (11.51%) were women from 32 countries and 3,328 (88.49%) were men from 47 countries. Female senior authors were most frequently from Europe (38.57%), whereas male senior authors were again predominantly from Asia (41.12%). The largest disparity in senior authorship was in Oceania (male-to-female ratio = 44), and the lowest in Latin America (male-to-female ratio = 4.1). Notably, the odds of a woman being the first author nearly doubled when the senior author was also a woman. Overall, over the 10-year period, the male-to-female ratio among first authors improved from 4.46 (2015–2016) to 3.25 (2023–2024), and among senior authors from 9.10 to 6.43.

Conclusion

Women remain underrepresented in first and senior authorship positions in gastrointestinal endoscopy research. These disparities may be influenced by limited female representation and mentorship in the field. Although gender gaps have narrowed over the past decade, sustained and coordinated efforts are needed to promote equity in academic publishing.