Introduction

The adenoma detection rate (ADR) is widely recognized as a quality indicator in colonoscopy based colorectal cancer (CRC) screening. ADR has been shown to be inversely associated with the risk of post colonoscopy colorectal cancer (PCCRC).^1,2
A wide variation on the ADR among endoscopy units has been observed in the Danish fecal immunochemical based colonoscopy screening programme since the initiation in 2014. The ADR varied from 39% to 67% among endoscopist units from 2014-2017.³

Aims & Methods

To investigate the association between ADR and the risk of PCCRC using multivariable Poisson regression. Endoscopy units were grouped in quartiles based on the ADR. PCCRC was defined as a colorectal occurred 6-36 months after the initial screening colonoscopy. The Danish colorectal cancer screening registry (from 2014-2017) and the Danish Cancer registry (from 2014-2020) were used to identify colonoscopies, screening detected CRCs and PCCRCs.

Results

The study covered 80,374 colonoscopies (performed at 20 endoscopy units), 4,829 screening detected CRCs and 356 PCCRCs. Mean ADR in quartile 1 (lowest) was 41.0%, range [38.8-44.3], quartile 2: 48.3% [46.2-50.0], quartile 3: 52.2% [50.2-53.6] and quartile 4: 60.0% [54.1-67.0]. The proportion of PCCRCs (of all CRC) declined from 8.8% in quartile 1 to 4.8% in quartile 4.
Results from the multivariable Poisson regression analysis (outcome = PCCRC, predictors = age, sex, ADR) are shown in Table 1. The analysis found increased risk for PCCRC among females and a falling risk of PCCRC with higher ADR quartile.


Table 1: Multivariable poisson regression analysis for PCCRC*

Conclusion

PCCRC is an important colonoscopy quality performance indicator, however the need for years of follow-up and large-scale data limits the use as an indicator for current colonoscopy performance. ADR is a viable alternative. The latest Danish colonoscopy screening report from 2021 still shows a wide variation in ADR highlighting the need for attention to colonoscopy performance in order to increase the efficacy of the CRC screening program.⁴

References

1) Corley DA, Jensen CD, Marks AR, et al. Adenoma Detection Rate and Risk of Colorectal Cancer and Death. N Engl J Med 2014; 370: 1298–1306
2) Kaminski MF, Wieszczy P, Rupinski M, et al. Increased Rate of Adenoma Detection Associates With Reduced Risk of Colorectal Cancer and Death. Gastroenterology 2017; 153: 98–105
3) Regionernes Kliniske Kvalitetsudviklingsprogram. Dansk tarmkræftscreeningsdatabase Årsrapport 2017. 2018; 1–105. https://www.regionshospitalet-randers.dk/siteassets/afdelinger/afdeling-for-folkeundersogelser/pdf-episerver/retningslinjer/dts_arsrapport-2017_final.pdf. Accessed the 28th of April 2023.
4) Regionernes Kliniske Kvalitetsudviklingsprogram. Dansk tarmkræftscreeningsdatabase Årsrapport 2021. 2022; 1–102. https://www.sundhed.dk/content/cms/45/61245_dts_aarsrapport2021_til-offentliggrelse_13122022.pdf. Accessed the 28th of April 2023.

Introduction

There are three main concepts in colorectal carcinogenesis. The first is the well-known “adenoma-carcinoma sequence”, while the second is the “saw-tooth lesion pathway”. In this concept, serrated lesions transform into early carcinomas. The third concept is the “de novo” pathway, in which early carcinomas can develop even in the absence of an adenoma. In this pathway, the cancer is thought to arise directly from the normal epithelium, rather than from an adenoma, and the cancer tends to progress at a faster rate and with a higher grade of malignancy. For diagnosing colorectal cancer, magnified endoscopy, specifically the Pit pattern classification, has proved to be useful. Recently, the endoscopic examination (EC classification) has been developed, and now not only structural atypia but also cellular atypia can be observed in vivo.
In this study, we aimed to clarify the endoscopic characteristics of colorectal cancer and demonstrate the usefulness of pit pattern classification and EC classification. Our study focused mainly on colorectal cancer that is considered to arise through the "de novo" pathway.

Aims & Methods

From April 2001 to December 2022, a total of 45,419 colorectal neoplasms, excluding advanced cancer that were resected endoscopically or surgically at Showa University Northern Yokohama Hospital. Among them, 37,098 were low-grade dysplasia, 6,802 were advanced dysplasia, and 1,519 cases were submucosal invasive carcinoma. In this study, we investigated the characteristics of depressed carcinomas with respect to Pit patterns and EC classification.

Results

Of all the T1 colorectal cancers, depressed lesions accounted for 61.4% (324/528). In contrast, flat and protruding lesions accounted for only 2.9% (575/19,578) and 2.7% (673/25,313) of T1 cancers, respectively. Flat (95.1% (18,619/19,578)) and raised (94.2% (23,844/25,313)) lesions showed mostly type IIIL and type IV pit patterns corresponding to adenomas. Among depressed lesions, 92.2% (486/528) were types IIIS, VI, and VN, corresponding to adenocarcinoma in pit pattern classification. On endoscopy, most of the flat or protruding lesions corresponded to adenomas and were classified as type EC2 in the EC classification, whereas the depressed lesions were mostly classified as EC3a and EC3b (91.2%), indicating invasive carcinoma according to the EC classification.

Conclusion

This study demonstrates that depressed colorectal cancer is prone to invade the submucosa, highlighting the need for magnifying endoscopy and endoscopy, regardless of the size of the lesion. Nonetheless, detecting this type of colorectal cancer can present a significant challenge. Thus, greater attention must be devoted to the morphological characteristics of depressed colorectal cancer during routine colonoscopy.

Introduction

Most clinical trials of systemic ulcerative colitis (UC) therapies exclude patients (pts) with isolated proctitis, who are considered a more treatment-refractory population, creating a need for clinical evidence. Etrasimod is an investigational, oral, once-daily, selective sphingosine 1‑phosphate (S1P)_1,4,5 receptor modulator in development for the treatment of moderately to severely active UC. The phase 3 etrasimod ELEVATE UC trials included pts with isolated proctitis (< 10 cm rectal involvement), provided they met all other eligibility criteria.¹

Aims & Methods

This post hoc analysis assessed predefined efficacy and safety outcomes in subgroups of pts with isolated proctitis and more extensive colitis (proctosigmoiditis/left-sided colitis/pancolitis). In ELEVATE UC 52 (NCT03945188) and ELEVATE UC 12 (NCT03996369), pts (aged 16–80 years) with moderately to severely active UC were randomised 2:1 to etrasimod 2 mg once daily or placebo. ELEVATE UC 52 comprised a 12-week (wk) induction period followed by a 40-wk maintenance period with a treat-through design. ELEVATE UC 12 comprised a 12-wk induction period. Clinical endpoints were assessed in pts with isolated proctitis (data pooled from both trials) and in pts with more extensive colitis (individual trial data). Sustained and corticosteroid-free clinical remission were assessed at Wk 52 (ELEVATE UC 52 only). Bowel urgency Numeric Rating Scale (NRS) was assessed at Wks 12 and 52. Safety was assessed up to Wk 52.

Results

This analysis included 64 (pooled; Wk 12) and 36 (ELEVATE UC 52; Wk 52) pts with isolated proctitis, and 397 (ELEVATE UC 52; Wks 12 and 52) and 326 (ELEVATE UC 12; Wk 12) pts with more extensive colitis. Similar proportions of pts with isolated proctitis achieved the predefined efficacy endpoints vs those with more extensive colitis (Table). Pts with isolated proctitis receiving etrasimod had similar improvements in urgency NRS scores vs those with more extensive colitis (mean change from baseline: Wk 12, -2.8 vs -2.9 [both trials]; Wk 52, -5.0 vs -4.1). Safety in pts with isolated proctitis was generally similar to that in the overall trial population.¹

Conclusion

Etrasimod treatment had similar efficacy in pts with isolated proctitis and in those with more extensive colitis. Prospective confirmation in larger pt cohorts with isolated proctitis is necessary. Safety was consistent with the overall population.¹

References

1. Sandborn WJ et al. Lancet 2023: Epub ahead of print

Disclosure

LPB: research: Takeda, Fresenius Kabi, Celltrion; consultancy: AbbVie, Alimentiv, Alma, Amgen, Applied MolecularTransport, Arena, Biogen, BMS, Celltrion, CONNECTBiopharm, Cytoki, Enthera, Ferring, Fresenius Kabi, Galapagos, Genentech, Gilead, Gossamer, GSK, HAC, IAG ImageAnalysis, Index, Inotrem, Janssen, Eli Lilly, Medac, Mopac, Morphic, MSD, Norgine, Novartis, OM, ONO, OSE, Pandion, Par'Immune, Pfizer, Prometheus, Protagonist, Roche, Sandoz, Takeda, Theravance, Thermo Fisher, TiGenix, Tillotts, Viatris, Vifor, Ysopia, Abivax; speaker: Galapagos, AbbVie, Janssen, Genentech, Ferring, Tillotts, Celltrion, Takeda, Pfizer, Sandoz, Biogen, MSD, Amgen, Vifor, Arena, Eli Lilly, Gilead, Viatris, Medac, Sanofi; stock: CTMA.
MCD: research: Janssen; consultancy: AbbVie, Arena, BMS, Celgene, Eli Lilly, Galapagos, Genentech, Gilead, Janssen, Pfizer, Prometheus, Takeda, Trellus Health, UCB; shares/royalties: Trellus; directorship/ownership interests: Trellus.
BES: research/grants: Arena, Janssen. Lecture/Speakers Bureau: BMS, Janssen, Lilly, Pfizer, Takeda. Consultancy: AbbVie, Alimentiv, Amgen, Arena, AstraZeneca, Boehringer-Ingelheim, BMS, Celltrion, Fresenius Kabi, Genentech, GSK, Janssen, Lilly, Merck, Pfizer, Prometheus Biosciences, Sun Pharma Global, Takeda Pharmaceuticals International, Teva Branded Pharmaceutical Products R&D. Shareholder/Stock Options: Ventyx Biosciences. Other non-financial support: Janssen, Lilly, Pfizer, Takeda.
JP: personal: AbbVie, Arena, Athos, Atomwise, Boehringer Ingelheim, Celgene, Celltrion, Ferring, Galapagos, Genentech/Roche, GSK, Immunic, Janssen, Mirum, Morphic, Nestlé, Origo, Pandion, Pfizer, Progenity, Revolo, Takeda, Theravance, Wassermann; grants: AbbVie, Pfizer.
SS: speaker: AbbVie, Arena, Biogen, BMS, Celgene, Celltrion, Dr. Falk, Fresenius, Janssen, MSD, Pfizer, Takeda; consultancy/advisory: AbbVie, Arena, Biogen, BMS, Celgene, Celltrion, Dr. Falk, Fresenius, Gilead, IMAB, Janssen, MSD, Mylan, Pfizer, Protagonist, Provention, Takeda, Theravance.
WR: speaker: AbbVie, Celltrion, Dr. Falk, Ferring, Janssen, Galapagos, MSD, Roche, Pfizer, Pharmacosmos, Shire, Takeda, Therakos; consultant: AbbVie, Amgen, AOP Orphan, Arena, Astellas, AstraZeneca, Bioclinica, Boehringer Ingelheim, BMS, Calyx, Celgene, Celltrion, Eli Lilly, Dr. Falk, Ferring, Galapagos, Gatehouse, Genentech, Gilead, Grünenthal, ICON, Index, Inova, Janssen, Landos Biopharma, Medahead, MedImmune, Microbiotica, Mitsubishi Tanabe, MSD, Novartis, OMass, Otsuka, Parexel, Periconsulting, Pharmacosmos, Pfizer, Protagonist, Provention, Quell, Sandoz, Seres, Setpointmedical, Sigmoid, Sublimity, Takeda, Teva, Therakos, Theravance, Zealand; advisory board: AbbVie, Amgen, AstraZeneca, Boehringer Ingelheim, BMS, Celgene, Celltrion, Galapagos, Janssen, Mitsubishi Tanabe, MSD, Pharmacosmos, Pfizer, Sandoz, Takeda; research: AbbVie, Janssen, MSD, Sandoz, Sanofi, Takeda.
BGF: consultant/advisory: AbbVie, AbolerIS, AgomAB, AllianThera, Amgen, AnaptysBio, Applied Molecular Transport, Arena, Avoro Capital, Atomwise, BIOJAMP, Biora, Boehringer Ingelheim, Boxer, Celsius, BMS, Connect, Cytoki, Disc Medicine, Duality, EcoR1, Eli Lilly, Equillium, Ermium, First Wave, FirstWord, Galapagos, Galen Atlantica, Genentech/Roche, Gilead, Gossamer, GSK, Hinge, HotSpot, InDex, Imhotex, Immunic, JAK, Janssen, Japan Tobacco, Kaleido, Landos, Leadiant, L.E.K., Lenczner Slaght, LifeSci, Lument AB, Millennium, MiroBio, Morgan Lewis, Morphic, Mylan, OM, Origo, Orphagen, Pandion, Pendopharm, Pfizer, Prometheus, Diagnostics, Play to Know AG, Progenity, Protagonist, PTM, Q32, Rebiotix, REDX, Roche, Sandoz, Sanofi, Seres, Silverback, Surrozen, Takeda, Teva, Thelium, TiGenix, Tillotts, Ventyx, VHSquared, Viatris, Ysios, YSOPIA, Zealand; speaker: AbbVie, Janssen, Takeda; Alimentiv Senior Scientific Director, provides central reading services; not a company employee, no equity stake; shareholder: Gossamer.
SD: consultancy/advisory: AbbVie, Allergan, Amgen, AstraZeneca, Biogen, Boehringer Ingelheim, Celgene, Celltrion, Ferring, Gilead, Hospira, Janssen, J&J, MSD, Mundipharma, Pfizer, Roche, Sandoz, Takeda, TiGenix, UCB Vifor; speaker: AbbVie, Amgen, Ferring, Gilead, Janssen, Mylan, Pfizer, Takeda; directorship/ownership interests: Gastroenterology and Endoscopy.
AJY: consultancy: Pfizer, Arena, Takeda, BMS; speaker: BMS.
GD’H: advisor: AbbVie, AstraZeneca, Alimentiv, BMS, Boehringer Ingelheim, Celltrion, Cosmo, Eli Lilly, Galapagos, GSK, J&J, Takeda, Pfizer, Polpharma, Prometheus, Tillotts, Ventyx; speaker: AbbVie, Boehringer Ingelheim, Celltrion, J&J, Takeda, Pfizer, Tillotts.
MG, KW, JCW, IM, AMcD, LB, CJR: Pfizer employees & shareholders.
SV: research: AbbVie, MSD, Pfizer, Galapagos, Takeda; consultancy: AbbVie, AbolerIS, Alimentiv, Arena, AstraZeneca, Avaxia, BMS, Boehringer Ingelheim, Celgene, CVasThera, Dr. Falk, Eli Lilly, Ferring, Galapagos, Genentech/Roche, Gilead, Hospira, Imidomics, Janssen, J&J, Materia Prima, MiroBio, Morphic, MrMHealth, MSD, Mundipharma, Pfizer, Prodigest, Progenity, Prometheus, Robarts Clinical Trials, Second Genome, Shire, Surrozen, Takeda, Theravance, Tillotts, Zealand; speaker: AbbVie, Dr. Falk, Ferring, Hospira, MSD, Takeda, Tillotts.

Introduction

Etrasimod is an investigational, oral, once-daily, selective sphingosine 1‑phosphate (S1P)_1,4,5 receptor modulator in development for the treatment of moderately to severely active ulcerative colitis (UC). In ELEVATE UC 52 (NCT03945188), etrasimod was superior to placebo (PBO) in achieving Week (Wk) 52 corticosteroid (CS)-free clinical remission (CR).¹

Aims & Methods

This post hoc analysis reports CS-free efficacy and safety in patients (pts) on baseline (BL) CS. Pts were randomised 2:1 to once-daily etrasimod 2 mg or PBO using a treat-through design (12-wk induction and 40-wk maintenance period). At entry, pts could receive concomitant CS (prednisone [≤ 20 mg/day], budesonide [≤ 9 mg/day] or equivalent) if on a stable dose ≥ 4 wks immediately before screening endoscopy; from Wk 12, CS tapering was recommended. CS-free was defined as withdrawal of CS ≥ 12 wks prior to assessment timepoint. CS-free outcomes assessed were CS-free CR at Wk 52, CS-free endoscopic improvement (EI) at Wk 52, and CR at Wk 12 + CS-free CR at Wk 52. From Wk 12, 4-wk CS‑free symptomatic remission (SR; 4 wk in contrast to ≥ 12-wks CS free) was analysed at each visit. Logistic regressions examined associations with CS-free efficacy at Wk 52. Safety was assessed.

Results

At BL, 32.2% (93/289) and 29.2% (42/144) of etrasimod and PBO pts received CS; of these, significantly more etrasimod vs PBO pts achieved CS-free CR at Wk 52, CS-free EI at Wk 52 and CR at Wk 12 + CS-free CR at Wk 52 (all p<0.05; Table). At Wks 40–52, there were significant differences (16.6–26.6%; p<0.05) in 4-wk CS-free SR between etrasimod and PBO. In this subpopulation, being biologic/Janus kinase inhibitor-naïve was not a significant predictor of 12-wk CS-free CR at Wk 52 (odds ratio [OR]: 3.61; 95% confidence interval [CI] 0.91, 14.39; p=0.07); age, per 10-year increase, was significantly associated (OR: 1.51; 95% CI 1.03, 2.22; p=0.04). Etrasimod vs PBO pts with concomitant CS at BL experienced slightly more adverse events (AEs; not exposure adjusted) (71.0% [66/93] vs 61.9% [26/42]) but fewer serious AEs (6.5% [6/93] vs 14.3% [6/42]), including serious infections (0% [0/93] vs 7.1% [3/42]).

Conclusion

More etrasimod vs PBO pts who received CS at BL met CS‑free efficacy endpoints. Four-wk CS-free SR with etrasimod was superior to PBO from Wk 40. Concomitant CS use at BL had no notable negative effect on the safety of etrasimod, consistent with the overall ELEVATE UC 52 population.¹

References

1. Sandborn W et al. Lancet 2023: Epub ahead of print.

Disclosure

BES: grants/research: Arena, Janssen; speaker: BMS, Janssen, Lilly, Pfizer, Takeda; consultancy/advisory board: AbbVie, Alimentiv, Amgen, Arena, AstraZeneca, Boehringer-Ingelheim, BMS, Celltrion, Fresenius Kabi, Genentech, GSK, Janssen, Lilly, Merck, Pfizer, Prometheus Biosciences, Sun Pharma Global, Takeda Pharmaceuticals International, Teva Branded Pharmaceutical Products R&D; stock: Ventyx Biosciences; non-financial support: Janssen, Lilly, Pfizer, Takeda.
YL: speaker: Pfizer Inc, Takeda, Abbvie, Jannsen; Consultancy, Advisory Committee/Board Member: Pfizer Inc, BMS, Takeda, Abbvie, Amgen BioJamp, Lilly.
DTR: grant support: Takeda, Helmsley Charitable Trust, GastroIntestinal Research Foundation; consultancy fees/is a member of advisory boards: AbbVie, AltruBio, ASLAN Pharmaceuticals, Athos Therapeutics, Bellatrix Pharmaceuticals, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Chronicles, Syneos, ClostraBio, Connect Biopharma, EcoR1, Genentech/Roche, Gilead Sciences, Iterative Health, Janssen Pharmaceuticals, Kaleido Biosciences, Eli Lilly, Pfizer Inc, Prometheus, Reistone, Seres Therapeutics, Takeda, Target RWE, Trellus Health; is on the Board of Trustees for Crohn’s & Colitis Foundation and Cornerstones Health, Inc; holds stock options in Alike Health, AltruBio, Datos Health and Iterative Health.
KBG: research support: Celltrion, Galapagos, Pfizer Inc; speaker honoraria and/or consulting fees: AbbVie, Celltrion, Ferring Pharmaceuticals, Immunic Therapeutics, Janssen, Novartis, Pfizer Inc, Samsung Bioepis, Takeda, Tillotts.
JP: personal: AbbVie, Arena, Athos, Atomwise, Boehringer Ingelheim, Celgene, Celltrion, Ferring Pharmaceuticals, Galapagos, Genentech/Roche, GSK, Immunic, Janssen, Mirum, Morphic, Nestlé, Origo, Pandion, Pfizer Inc, Progenity, Revolo, Takeda, Theravance Biopharma and Wassermann; grant support: AbbVie, Pfizer Inc.
MG: employee & shareholder of Pfizer AG.
WW, KS, JCW, CCS: employees & shareholders of Pfizer Inc.
KW: employee & shareholder of Pfizer Canada Inc.
SS: speaker: AbbVie, Arena, Biogen, Bristol-Myers Squibb, Celgene, Celltrion, Dr. Falk Pharma, Fresenius, Janssen, MSD, Pfizer Inc, Takeda; consultancy/advisory: AbbVie, Arena, Biogen, Bristol-Myers Squibb, Celgene, Celltrion, Dr. Falk Pharma, Fresenius, Gilead Sciences, IMAB, Janssen, MSD, Mylan, Pfizer Inc, Protagonist, Provention Bio, Takeda, Theravance.

Introduction

Peri-pancreatic fluid collections (PFCs) are frequent complications of acute pancreatitis and their management, especially in the presence of necrosis, is often challenging. Invasive interventions are indicated in case of PFC infection or symptoms related to organ compression. Endoscopic ultrasound (EUS)-guided transluminal drainage rapidly developed over time and the introduction of new dedicated stents represented a game changer of PFC treatment. In particular Bi-Flanged Metal Stent (BFMS) and Lumen Apposing Metal Stent (LAMS), with their technical characteristics, facilitate to create a stable connection between the gastrointestinal wall and the target cavity, allowing the introduction of the endoscope through the stent for direct therapeutic intervention, reporting high rates of technical and clinical success. To date, only one retrospective study have compared Nagi and Hot-Axios for EUS-guided drainage of PFCs.

Aims & Methods

The present study aimed to retrospectively evaluate the safety, technical and clinical success of the two different dedicated metal stents for EUS-guided drainage of PFC. Data from a large multicenter series of patients with PFCs treated with Hot-Axios and Nagi stents were retrieved among 30 italian centers during a 5-year period (January 2016–July 2020). Technical and clinical success, rate of adverse events were taken into account as outcome measures. To overcome biases owing to the different distribution of covariates among patients who were treated with the two kinds of stent, a 1-to-1 match was created using propensity score analysis.

Results

Out of 476 patients underwent EUS-guided drainage of PFC, 386 were treated with Hot-Axios and 90 with Nagi stent, with a median follow-up of 290 days (95% CI 244 to 361). After 1:1 propensity score matching two groups were compared, 84 subjects who experienced Hot-Axios and 84 Nagi stent, resulting well comparable in terms of several variables. Median age was 62 (49.5-73) years in the Hot-Axios group and 63 (50-74) years in the Nagi group (p=0.40), male patients were 70% and 61% in the two groups, respectively (p=0.59). WON represented 39% of cases in the Hot-Axios and 32% in the Nagi group (p=0.70); 52% and 61% of PFCs were located in the body of pancreas in the two groups respectively (p=0.62) with a median width of 92 mm (61-120) in the Hot-Axios and 88 mm (56-110) in the Nagi group (p=0.25).
The two stents did not differ in terms of adverse events (AE) rate (13% versus 15%, p=0.29).
Overall, 11 AEs were observed in the Hot-Axios group, of which 3 (3.5%) mild, 4 (4.7%) moderate, 3 (3.5%) severe and 1 (1.1%) fatal, whereas 13 AEs were registered in the Nagi group, of which 3 (3.5%), 5 (5.9%), 3 (3.5%), and 2 (2.3%) mild, moderate, severe and fatal, respectively (p=0.63). Most common AE was bleeding (5.9% in both groups). Collection recurrence was observed in 4 cases after Hot-Axios (4.7%) and 3 cases (3.5%) after Nagi stent (p=1.0).
Technical and clinical success in the two groups were respectively 92% versus 95% (p=0.36) and 91% versus 94% (p=0.64).

Conclusion

Although literature is not univocal on which type of stent offers the best outcome for EUS-guided PFC drainage, our study demonstrates that, among dedicated metal stents, Hot-Axios and Nagi stent have similar technical and clinical success rate with comparable safety profile, suggesting that the choice of one stent over another should be multifactorial, based on clinical and technical aspects and/or personal expertise, rather than just efficacy rate.

Disclosure

Chiara Coluccio is lecturer for Steris.
Andrea Anderloni is consultant for Boston Scientific, Olympus and Medtronic.
Carlo Fabbri is consultant for Boston Scientific and lecturer for Steris and Q3 Medical.
All the other authors have no conflict of interest to declare

Introduction

According to the European Society of Gastrointestinal Endoscopy guidelines, non-invasive treatments, such as endoscopic treatment (ET) and extracorporeal shock wave lithotripsy (ESWL), are available for treating pancreatic head stones. However, their efficacy for pancreatic tail stones (PTS) remains unclear.

Aims & Methods

The purpose of this study was to investigate the efficacy of ET and ESWL in the management of PTS. We conducted a single-center, retrospective study of 45 painful chronic pancreatitis patients with PTS and pancreatic body stones (PBS) who underwent non-invasive treatments between January 2008 to December 2021. The primary outcome was to determine the rates of pancreatic stone removal using ET and PTS. We also focused on and evaluated the “crab claw sign” specific to the pancreatography of caudal main pancreatic duct (MPD) stones. The secondary outcome was to identify procedural factors using logistic regression analysis.

Results

PTS (n=18) group had a significantly lower complete stone removal rate than PBS (n=27) group (22.2% versus 55.6%; P=0.03). ERCP revealed crab claw signs in 60% of cases (PTS, 77.8%; PBS, 48.1%; P=0.07), of which 48.1% could advance the guide wire into the peripheral MPD (PTS, 42.9%; PBS, 53.8%; P=0.7). Multivariate analysis revealed that PTS (OR, 0.23; 95% CI, 0.06–0.88; P=0.03), stone diameter (OR, 0.23; 95% CI, 0.06–0.88; P=0.03), number of ESWL total shots (OR, 0.06; 95% CI, 0.008–0.56; P=0.01), and crab claw sign (OR, 0.07; 95% CI, 0.01–0.28; P=0.0002) were significant factors associated with failure of stone removal.

Conclusion

Our findings indicate that large PTS with crab claw signs resist ET/ESWL treatments. These findings contribute to determining whether PTS patients should initially undergo non-invasive therapy or surgical treatment.

References

Dumonceau JM, Delhaye M, Tringali A, et al. Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - updated August 2018. Endoscopy 2019;51:179-193.

Introduction

The effect of analgesic modalities on short term outcomes in acute pancreatitis (AP) is unknown. Opioids are frequently used in AP but there are concerns regarding safety from preclinical models of AP. The aim of this study was to assess the effect of different analgesic modalities, in particular opioids, on the severity, morbidity, and mortality in hospitalized patients with AP.

Aims & Methods

This prospective cohort study recruited consecutive patients admitted with a first episode of AP from 1 April to 31 June 2022 with 1-month follow up. Data on aetiology of AP, clinical course, and analgesic treatment were collected. The primary outcome was the association between analgesic type and severity of AP. Statistical analysis was performed using univariate comparisons, multivariable regression, and mediation analysis.

Results

A total of 2,119 patients were recruited from 118 centers in 27 countries. The patients were 53 % male sex with median age of 55 years (IQR, 41-71). The most common aetiology of AP was gallstones (58%), followed by alcohol (21%). Pain duration prior to admission was >24 hours in 978 (47%) patients and <12 hours in 530 (25 %) patients. As for the first analgesic modality simple analgesics were administered in 1,456 (70%) patients and opioids were given in 521 (25%) patients. There were 1,383 (69%) patients who had opioid use at any time during admission. On univariate analysis, moderately severe/severe AP was associated with male sex, younger age, alcohol aetiology, predicted severe AP, higher pain scores, and opioid treatment (all p≤0.01). Also, on univariate analysis patients who received opioid treatment were at increased risk of severe AP, organ failure, necrosis, and longer length of admission (all p≤0.01). On multivariate analysis alcohol aetiology, predicted severity of AP and opioid treatment showed increased risk for moderately severe/severe AP (all p<0.001). Mediation analysis showed a significant direct effect of opioid use on AP severity (p<0.001).

Conclusion

This prospective multicentre study suggests that opioids have a direct effect on the severity and morbidity of AP. Further randomized controlled trials should be designed to test the safety of opioids in AP.