Clinical Case Summary

A 74-year-old man with a history of distal gastrectomy was hospitalized because of left lower extremity edema. Occlusion of left common iliac vein (CIV) and severe stenosis of left external iliac vein (EIV) were found (Video.1). Stents were used to release the edema. In order to investigate the pathogenesis, contrast-enhanced computed tomography was then carried out. Diffuse enlargement and continued enhancement of pancreas were found (Figure.1). Soft-tissue mass with low density grew around inferior mesenteric artery, left common iliac artery (CIA), left internal and external iliac arteries (Figure.2). Left CIV and EIV were compressed by the soft-tissue mass. Elevated serum immunoglobulin G4 (IgG4) was 598mg/dl. Therefore, the diagnosis of autoimmune pancreatitis (AIP) was confirmed. The soft-tissue mass was considered as AIP-associated retroperitoneal fibrosis (RF). The left lower extremity edema was actually attributed to AIP. Glucocorticoid was initially administered at 60mg/day for 2 weeks, and tapered by 5mg every week. Until to 20mg/day, glucocorticoid was tapered by 2.5mg every week. And it was finally maintained at a dose of 5mg/day.
Sausage-like shape is a typical sign of AIP¹. That serum IgG4 is more than 135mg/dl can be used for differential diagnosis from pancreatic cancer². According to the guideline², AIP was definitely confirmed based on diffuse enlargement of pancreas and elevated serum IgG4. Patients sometimes suffer from extra-pancreatic lesions, which are so called other organ involvement², such as RF. In this patient, the space between left CIA and vertebra became much narrow due to AIP-associated RF. Its compression contributed to the occlusion of left CIV that ran through the gap, resulting in the clinical symptoms of left lower extremity venous reflux disorder. This is the first AIP patient who primarily presented with left lower extremity edema. And no patient has been reported to suffer from left CIV occlusion caused by AIP-associated RF.

References

1. Masamune AA-O, Kikuta K, Hamada S, et al. Nationwide epidemiological survey of autoimmune pancreatitis in Japan in 2016. Journal of gastroenterology 2020;55(4):462-470.
2. Okazaki K, Kawa S, Kamisawa T, et al. Amendment of the Japanese consensus guidelines for autoimmune pancreatitis, 2020. J Gastroenterol 2022;57:225-245.

Introduction

There has been a shift from percutaneous drainage towards endoscopic ultrasound (EUS)-guided drainage for management of post-operative pancreatic fluid collections (POPFC). However, available series have been limited by sample size and little is known about the factors that may influence clinical success.

Aims & Methods

Our aim was to evaluate the outcomes of EUS-guided drainage of POPFC following pancreatic surgery and identify predictors of clinical success.
We performed a retrospective review of patients who underwent EUS-guided drainage of POPFC between 2014 and August 2024 at three academic centers. Primary outcome was clinical success, defined as the complete radiological regression of the collection and resolution of symptoms without the need for additional drainage procedures.

Results

In total, 265 cases were included (mean age 64 [SD±13.9] years, 37% pylorus-resecting pancreatoduodenectomy). Early drainage (≤14 days) was performed in 52% of cases (n=138) and DPPS were used in 209 cases (79%).
Clinical success with a single EUS drainage procedure was achieved in 160 cases (60.4%). Step-up interventions were required in 67 patients (25.3%), 37 of which required endoscopic revision only. Technical success was achieved in 90% (n=238) and adverse events occurred in 43 cases (16%).
Stent type, drainage timing, splenectomy and drainage route did not seem to significantly influence clinical success. Multivariate analysis including stent type and surgical history, showed that distal pancreatectomy was an independent risk factor for clinical failure.

Conclusion

EUS-guided drainage of POPFC was effective in the majority of cases with a single procedure, although distal pancreatectomy was suggested as an independent risk factor for clinical failure. These results further support the use of EUS-guided drainage for the management of postoperative collections.

Disclosure

HH declares no competing interests. MB received trial support from Boston Scientific and holds consultancy agreements with Dekra, Ovesco and Prion Medical. GV received lecture fees from Boston Scientific and travel grants from Pentax Medical and Euromedical. RVW holds a consultancy agreement with Boston Scientific. Schalk van der Merwe holds the Cook chair in Interventional endoscopy, has consultancy agreements with Cook, Pentax and Olympus and co-chairs the Boston-Scientific Chair in Therapeutic Biliopancreatic Endoscopy.

Clinical Case Summary

In pancreaticobiliary cancer, which has a poor prognosis, early recurrence often occurs even after curative resection. Recurrence around major blood vessels is also common, and it is possible that micro-cancer cells may remain around major vessels even after resection is achieved. Therefore, novel therapeutic strategy are needed to improve prognosis and achieve long-term survival. In this situation, high-intensity focused ultrasound (HIFU), a new non-invasive treatment, is expected to be used not only as neoadjuvant therapy but also as adjuvant therapy.
A 59-year-old woman underwent pancreaticoduodenectomy and cholecystectomy for ampullary carcinoma in May 2022. After that, in April 2023 during postoperative adjuvant chemotherapy, left supraclavicular lymph node metastasis was suspected, and chemotherapy was continued. A PET-CT scan in January 2024 showed local recurrence around the SMA to the aorta, and GEM+CDDP+Durvalumab therapy was administered as systemic chemotherapy from February 2024. After 6 courses, PET-CT and CT showed a reduction in the size of the tumor. Aiming for a negative surgical margin, HIFU therapy was performed in September 2024 as a local treatment at the site of local recurrence (7 cm) from around the SMA to around the aorta, the superior mesenteric vein, and the posterior side of the renal vein. One week later, tumor resection was performed. Although the pathological findings showed a negative margin, chemotherapy was performed as a postoperative adjuvant therapy. After that, the tumor marker was again elevated, so HIFU was performed again in December 2024 as an adjuvant therapy on the soft tissue at the resection site. The tumor marker decreased, and the patient is currently under observation.
In conclusion, surgical resection and multidisciplinary treatment with chemotherapy and HIFU therapy seem to be promising treatments for pancreaticobiliary cancer with poor prognosis to improve the prognosis and achieve long-term survival.

References

none

Disclosure

none

Introduction

The Maastricht V/ Florence Consensus has updated guidelines for the management of Helicobacter Pylori (HP) infection with special emphasis in high clarithromycin resistance settings as it is the case in our country. In line with the recommendations of the European Guidelines on surgery of severe obesity [1] and the recommendations of the American Society of Gastrointestinal Endoscopy on endoscopy of the bariatric patient [2) a policy of systematic HP screening and overtime updated eradication was implemented in obese patients undergoing Roux-en Y gastric bypass (RYGB) surgery.

Aims & Methods

Five year period (2020-2024) single center study. The aim was, in obese patients undergoing RYGB surgery, to assess the cumulative HP eradication rate by adopting, at first line, a 10 days bismuth quadruple therapy (BQT) - proton pump inhibitor (PPI) bid and three-in-one single capsule containing bismuth, metronidazole, and tetracycline qid - and, at second line, a 14 days levofloxacin based therapy ( LBT) – PPI bid, amoxicillin 1000 mg bid and levofloxacin 500mg bid. HP infection status was assessed, at baseline, by histology or urea breath test and post treatment, by urea breath test 4-6 weeks after the end of the therapy.

Results

One thousand four hundred and forty-nine consecutive HP‑positive patients completed BQT treatment: 1160 (80.1%) female, age 43.5 (±10.5) years, median age of 44 years), age range of 18-69 years. HP was eradicated in 1220 patients – 84.2% (95%CI: 82.2%-86.0%). In the remaining 229 patients, 87 patients withdrew and HP was eradicated in 118 patients out of 145 with LBT. The intention to treat (ITT) and per protocol (PP) cumulative eradication rates were, respectively, 92.3% (95%CI: 90.9%-93.6%). and 98.0% (95%CI: 97.1%-98.6%). Eradication rates were not significantly different by gender and age.

Conclusion

By adopting the Maastricht V/ Florence Consensus BQT first line therapy and second line LBT therapy, high ITT and PP cumulative HP eradication rates are achieved leaving only a residual number of obese patients undergoing RYGB in need of the culture and susceptibility testing prior to third line treatment.

References

1. Fried M, Hainer V, Basdevant A, et al. European Guidelines on surgery of severe obesity. . International Journal Of Obesity 2007;31:569-577.
2. ASGE Guidelines. Role of endoscopy in the bariatric patient. Gastrointest Endosc 2008; 68:1-10.

Disclosure

NO CONFLICT OF INTEREST

Introduction

EUS-guided gastroenterostomy (EUS-GE) is increasingly used in the management of Gastric Outlet Obstruction. However, significant variability exists in technical choices which might account for heterogeneous clinical outcomes. The aim of this Delphi methodology was to address open questions and establish a consensus on best practices to gather expert opinions on key aspects of EUS-GE.

Aims & Methods

A panel of 25 international leading experts in EUS-GE was invited to revise literature around the technique. A Delphi process was conducted over three rounds, with each round involving anonymous voting on 29 predefined statements, using a 5-point Likert scale (1: strongly disagree – 5: totally agree). Responses were analysed through Medians [Interquartile Ranges], with pre-defined thresholds for approval, revision or discard of the statement. Statements reaching final consensus were graded based on the strength of agreement, defined as the proportion of responses rated 4 or 5.

Results

Response rate was 88% in Round 1 and 100% in Round 2 and 3. Among 29 statements, eight were approved at Round 1, eighteen at Round 2 and four at Round 3, while two were ultimately rejected.
There was early and excellent agreement (>95%) on the need of fluoroscopy for EUS-GE, the need for electrocautery-enhanced Lumen Apposing Metal Stent (LAMS), and the preference for free-hand release. All panellists agreed that endoscopists performing EUS-GE should be familiar with management of Adverse Events (AEs) such as bleedings or perforations. After discussion, excellent agreement was obtained for the management of AEs (misdeployments and bleedings) and LAMS dysfunctions.
Final Strong agreement (>90%) was reached for preferred patient positioning, the required sedation and the preference for saline solution for jejunal distention.
Extensive discussion with final Moderate agreement (>80%) was reached on the use of dye, the preference for catheter-assisted EUS-GE instead of endoscope- or needle-directed instillation, the typical location for EUS-GE and the operative space required for LAMS release.
Statements on the use of contrast and the choice between WEST and EPASS techniques were removed due to lack of agreement.

Conclusion

Despite technical differences (such as the preference of a jejunal catheter or a double-balloon catheter) most EUS-GE experts agree on key technical principles, providing valuable guidance on the standardization of EUS-GE in clinical practice. Conversely, certain topics showed limited agreement, identifying future research priorities in the field of EUS-GE.