Clinical Case Summary

Pancreatic tuberculosis is rare, even in regions where the disease is highly prevalent. Its incidence is less than 4.7% (14/297 cases) in a large tuberculosis autopsy series by Auerbach et al. (1944). Symptoms are vague and non-specific, while radiologic features can mimic pancreatic carcinoma. Due to its nature of presenting as a pancreatic mass, unwarranted surgical interventions may diminish the patient’s quality of life. We presented a case of a 53-year-old male with a ten-week history of abdominal pain, febrile episodes, and weight loss. Ultrasound and magnetic resonance cholangiopancreatography (MRCP) revealed a pancreatic head and body mass causing moderate extrahepatic, intrahepatic, and mild pancreatic ductal dilatation. There was also infiltration of the medial wall of the second part of the duodenum and the posteroinferior wall of the first portion of the duodenum. Endoscopy showed duodenal narrowing due to the mass encroaching on the duodenum; hence malignancy was highly considered. However, a biopsy of left cervical lymphadenopathies seen revealed chronic granulomatous inflammation morphologically compatible with a tuberculous etiology. The patient underwent exploratory laparotomy with pancreatic head mass biopsy, where the frozen section revealed chronic granulomatous inflammation, possibly tuberculous in etiology, hence proceeded with gastrojejunostomy and cholecystojejunostomy. Postoperatively, the patient was stable and sent home with six months of anti-Koch medication, with a final diagnosis of pancreatic tuberculosis. Repeat MRCP revealed a resolution of the previously seen pancreatic head and body mass and biliary dilatation. Conservative management usually successfully alleviates symptoms and even the complete regression of mass lesions. The excellent response to anti-Koch’s medication makes it imperative that these patients are diagnosed early and managed appropriately to avoid unwarranted surgery and associated morbidity.

References

Auerbach O. Acute Generalized Miliary Tuberculosis. The American Journal of Pathology. 1944Jan;1(20):121–136.
Chaudhary P, Bhadana U, Arora MP. Pancreatic tuberculosis. Indian Journal of Surgery. 2015;77(6):517–24.

Disclosure

No conflict of interest was foreseen by the authors.

Introduction

Although Endoscopic Retrograde Cholangiopancreatography (ERCP) has played an important role in the diagnosis and treatment of biliary and pancreatic diseases since its inception, the gallbladder is still considered a “blind spot” or inaccessible area for ERCP.

Aims & Methods

This study was intended to evaluate the technical success rate, safety, and clinical application value of per-oral cholangioscopy-guided transpapillary cystic duct approach for Gb-NOEES, and to explore the feasibility of Natural Orifice Endoluminal Endoscopic Surgery (NOEES) in the diagnosis and treatment of gallbladder diseases.
Patients with gallbladder diseases who received Gb-NOEES treatment from January 2023 to November 2024 were retrospectively included in a single-center study. Inclusion criteria: Patients are preoperatively diagnosed with gallstones, gallstones combined with common bile duct stones, gallstones combined with intrahepatic stones, acute cholecystitis, and gallbladder polyps. Exclusion criteria: patients with asymptomatic gallstones, patients with gallbladder cancer, and patients at risk of gallbladder cancer. All procedures were performed by experts with ≥10 years of experience in digestive endoscopy, and postoperative follow-up period ranged from 2 to 26 months.

Results

A total of 100 patients were included (58 males and 42 females, with an average age of 47±15.1). The disease distribution is shown in Table 1. The technical success rate of Gb-NOEES was 99% (99/100), and the average operative time was 130±59 minutes. The complication rate was 4%: 3 cases of gallbladder perforation (1 case of successful conservative treatment, and 2 cases of conversion to laparoscopic surgery), and 1 case of postoperative bleeding (successful conservative treatment). No severe pancreatitis or death occurred. Treatment outcomes: Gallstone clearance rate was 98% (78/80), with the largest stone measuring 4.0 cm, and up to 52 stones removed in a single operation. Complete excision rate of gallbladder polyps was achieved in 100% (15/15), with long diameter of polyps ranging from 4 mm to 15 mm, and up to 8 polyps excised in a single operation. Drainage success rate for acute cholecystitis was 100% (4/4). One case of early-stage gallbladder cancer was incidentally detected. During the follow-up period, the recurrence rate of stones was 2.5% (2/80), and there was no recurrence of polyps.

Conclusion

Gb-NOEES demonstrated favorable safety profile (complication rate was 4%) and high efficacy (overall success rate was 98%) in the diagnosis and treatment of gallbladder diseases. This technique has advantages of both lesion removal and organ preservation, offering a new minimally-invasive treatment option for gallbladder diseases. However, its clinical application value requires further validation through multi-center studies.

Table 1. Disease Distribution of Patients

Disclosure

There is no conflict of interest.

Introduction

Colon Capsule Endoscopy (CCE) offers a non-invasive alternative to colonoscopy for lower gastrointestinal (GI) investigations. However, its adoption is limited by lengthy reading times, reader fatigue, and variable diagnostic accuracy. These factors are often influenced by bowel preparation quality and completion rates. Artificial intelligence (AI) has shown the potential to improve diagnostic accuracy of polyp detection and reduce reading times in capsule endoscopy.

Aims & Methods

Objective(s): The primary aim is to assess the diagnostic accuracy of Computer-Aided Detection (CADe) system (AiSPEED™) assisted CCE reading using full-video analysis in a real-world clinical setting. Secondary outcome was to assess a) non-inferiority compared to standard clinician reading in detecting polypoid lesions and b) mean reading time.
Methods: CESCAIL study is a multi-centre study of 14 UK centres recruited 720 participants between November 2021 and September 2024. Participants (prospectively and retrospectively enrolled ) included those ≥18 years referred for CCE under the urgent cancer pathway or for post-polypectomy surveillance. CCEs were performed using PillCam™ COLON 2 and analysed using AiSPEED™. CCE videos were evaluated by separate clinicians who provided standard readings, while AI-assisted reading included an AI-assisted pre-reader review and subsequent clinician validation.

Results

720 patients were enrolled, with 673 included in the final analysis. The capsule excretion rate before battery depletion was 77.1%, with adequate bowel preparation achieved at 78.1% (with standard) and 74.0% (with AI-assisted reading) (McNemar p=0.108). In the per-patient analysis, the diagnostic yield for detecting polyps was 63.6% (428/673) for standard reading and 70.6% (475/673) for AI-assisted reading, using the expert panel as the reference standard. These findings confirmed both non-inferiority (p<0.001) and superiority (p<0.001) of the AI-assisted reading. The diagnostic accuracy for detecting polyps requiring follow-up procedure (flexible sigmoidoscopy/colonoscopy) was 0.96 (95% CI: 0.95–0.98) for AI-assisted reading, compared to 0.91 (95% CI: 0.89–0.93) for standard reading (p<0.0001) (see Table 1). The mean reading time per video was 8.7 minutes for AI-assisted reading compared to 47.3 minutes for standard reading, representing a 5.4-fold reduction.

Conclusion

AI-assisted reading with AiSPEED™ offers the potential for greater accuracy in polyp detection and significantly reduced clinician reading times during CCE examination compared to standard reading methods.

References

1. Moen S, Vuik FER, Kuipers EJ, Spaander MCW. Artificial Intelligence in Colon Capsule Endoscopy-A Systematic Review. Diagnostics (Basel). 2022;12(8).
2. Mota J, Joao Almeida M, Mendes F, Martins M, Ribeiro T, Afonso J, et al. A Comprehensive Review of Artificial Intelligence and Colon Capsule Endoscopy: Opportunities and Challenges. Diagnostics (Basel). 2024;14(18).
3. Spada C, Piccirelli S, Hassan C, Ferrari C, Toth E, Gonzalez-Suarez B, et al. AI-assisted capsule endoscopy reading in suspected small bowel bleeding: a multicentre prospective study. Lancet Digit Health. 2024;6(5):e345-e53.
4. Spada C, Hassan C, Galmiche JP, Neuhaus H, Dumonceau JM, Adler S, et al. Colon capsule endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2012;44(5):527-36.
5. PillCam COLON 2 for investigation of the colon through direct visualisation [Internet]. NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE. August 2024. Available from: https://www.nice.org.uk/guidance/gid-dg10083/documents/final-scope-2.

Disclosure

Hagen Wenzek serves as the CEO, and Elizabeth White is the Project Manager at Corporate Health International which owns the ​intellectual property of AiSPEED^TM

Introduction

Ustekinumab is a monoclonal antibody that targets the p-40 subunit of the interleukins IL-12 and IL-23 and is used to treat moderate to severe Crohn's disease.

Aims & Methods

The present study aims to capture the experience of a tertiary center regarding the use of ustekinumab in patients with Crohn's disease in clinical practice [real-world] settings. This is a retrospective cohort study. Demographic and disease-related data on the day of ustekinumab initiation were collected. Study primary endpoint of the study was the persistence of treatment at the end of the first year without the administration of corticosteroids (cs-free). Secondary endpoints were the persistence of treatment at the end of the first, second and fourth year with and without the need for corticosteroids. The statistical program SPSS-23 was used for the analysis.

Results

In total, 99 patients have been registered until this point [women, 52.5%; mean age 42 years, SD=16; median disease duration=6 years IQR=1.5-11;A1/A2/A3, 6.1/65.7/28.3%; L1/L2/L3/L4, 58.6/7.1/34.3/12.1%; B1/B2/B3, 51.5/30.3/18.2%; perianal disease 26%]. Among study participants, 68.7% reported history of exposure to at least one biologic agent and 35.4% had undergone a CD-related surgery. At ustekinumab initiation 6.1% were receiving concomitant azathioprine, 4% methotrexate and 32.3%corticosteroids. 75.8% (75/99) continue ustekinumab with a median duration of administration of 14.5 months (range=0.5-66). Cs-free persistence in one-year was observed in 70.1% (54/77), cs-free persistence in two-years in 59.2% (29/49), and cs-free persistence in four-years in 45% (9/20). Simple persistence in one-, two- and four-years was observed in 84.4% (65/77), 61.2% (30/49) and 55% (11/20) respectively. Seven patients (9.3%) required intensification (90mg subcutaneously every 4 weeks) and one (1.3%) required reinduction (one-time weight-adjusted intravenous administration) due to loss of response. Patients that achieved cs-free persistence in one year were associated with higher persistence in two- and four-years compared with those who received corticosteroids during the first year of ustekinumab administration (P<0.001). Patients with a history of CD-related surgery achieved higher percentages of persistence (P<0.05). In univariate logistic regression, cs-free persistence in one-year was found to be associated with Harvey-Bradshaw Index [HBI] (OR=0.81, P=0.025), CRP [mg/L] (OR=0.96, P=0.059), history of CD-related surgery (OR=3.52, P=0.041), and neutrophils>5820/μL (OR=0.19, P=0.021). In multivariate logistic regression, cs-free persistence in one-year was found only to be negatively associated with HBI (OR=0.44, 95%CI: 0.24-0.81, P=0.008). No serious infection or malignancy has been observed.

Conclusion

Our analysis showed that patients with Crohn's disease achieved high rates of persistence on ustekinumab without the need of corticosteroids administration up to 4 years after the initiation of treatment. Patients with more severe diasease at drug initiation experienced lower persistence. Long-term administration of ustekinumab is not associated with any new safety concerns.

Disclosure

GB has acted as advisor/lecturer for Janssen, Pfizer, Takeda, Abbvie, MSD, Mylan, Genesis Pharma, Adacyte Therapeutics, Amgen, Ferring, Cooper; Funding (Grants/Honoraria): Pfizer, Takeda, Abbvie, Aenorasis; Research/Clinical Trials: Abbvie, Takeda. Genesis Pharma, Cooper.