Introduction

The undetermined pancreatic cystic neoplasms represent 20-30% of the total number of pancreatic cystic lesions(PCL). The diagnostic accuracy of endoscopic ultrasound (EUS) morphology is 51%. Endoscopic ultrasound-guided fine-needle aspiration(EUS-FNA) should be performed for differentiating between mucinous and non-mucinous pancreatic cysts when the characterization of the cyst cannot be made on the basis of non invasive imaging techniques.

Aims & Methods

Our aim was to assess the utility of the Neutrophil gelatinase-associated lipocalin(Ngal) concentration alone or combined with glucose level in cyst fluid obtained by EUS with EUS-FNA for discriminating between mucinous and non-mucinous PCL's.
This prospective study was performed between april 2018 and may 2020 at one tertiary referral hospital and included 63 patients , 30 with undetermined pancreatic cysts (group A) and the controlled group was represented by 33 patients with pancreatic pseudocysts after acute pancreatitis drained by EUS (group B). The patients from group A underwent EUS-FNA for liquid analysis and the patients from group B had liquid collection during the drainage of pseudocysts. The final diagnosis was based on surgery or EUS results (morphology, cytology, glucose and carcinoembryonic antigen(CEA) intracystic level) or on imaging during follow-up (24 month). We performed sandwich enzyme-linked immunosorbent assays (ELISA) for cystic and serum Ngal determination and measured glucose levels by a hand glucometer.

Results

The final diagnosis was pseudocyst in 33 patients, serous cystadenoma in 6, mucinous cystadenoma in 3, intraductal papillary mucinous neoplasms in 19 patients, and ductal adenocarcinoma in 2 patients. The cystic fluid analysis of these patients showed that the mean Ngal value for the serous cystic adenomas was 336ng/dl, 728ng/dl for the mucinous lesions and 1116ng/dl for the pseudocysts. The intracystic Ngal concentration (cut-off ≥ 500 and ≤ 800ng/dl) had diagnsotic sensitivity 70.8%, and specificity 92.3% for mucinous cysts. Serum Ngal concentration had no diagnostic contribution. The cystic glucose levels (cut-off ≤ 22mg/dl) had sensitivity 83.3% and specificity 82.1% for mucinous lesions. Combined glucose(cut-off ≤ 22mg/dl) and Ngal(cut-off ≥ 500 and ≤ 800ng/dl ) testing showed sensitivity of 58,3 and specificity 100% for mucinous cysts. Wheras either positive Ngal (cut-off ≥ 500 and ≤ 800ng/dl) or glucose (cut-off ≤ 22mg/dl) testing showed sensitivity 95.8% and specificity 74.4%.

Conclusion

Pancreatic cyst fluid NGAL concentration alone and combined with glucose level appeared to be useful in discriminating mucinous cysts.

References

State‑of‑the‑Art Update of Pancreatic Cysts -Andrew Canakis · Linda S. Lee2 Digestive Diseases and Sciences (2022) 67:1573–1587

Disclosure

Nothing to disclouse

Introduction

The quality of colonoscopy is influenced by patient and operator factors. Studies investigating operator attentional fatigue on adenoma detection rate (ADR) have yielded conflicting results.

Aims & Methods

This study aims to compare ADR, polyp detection rate (PDR) and sessile serrated lesion detection rate (SSLDR) and complication rates between elective colonoscopies performed early and late in the list, across multiple operators (n>15), over 10 years, in a tertiary Brisbane (Australia) hospital.
A retrospective study was conducted on elective colonoscopies performed between 2012 and 2022 at The Prince Charles Hospital. ‘Early procedures’ are defined as procedures starting in the first hour of the first procedure starting and ‘late procedures’ are defined as procedures starting within the last hour of the last procedure starting. This pre-defined early and late procedures were used as surrogate markers for operator fatigue, accounting for a possible non-linear relationship between time and onset of fatigue, as well as the variation in number of colonoscopies performed every hour. Timing and the order of colonoscopy were used as alternative surrogates, in a secondary analysis.
Logistic regression was performed on all categorical outcome variables, and Poisson regression was modelled on continuous outcome variables, due to their non-linear distribution. Multivariate analysis included all potential confounding variables related to outcomes of interest. Statistical significance was defined as a P-value less than 0.05. Statistical analyses were performed using the SAS® statistical software (SAS Institute Inc, USA).
Exclusion included; surveillance for IBD and elective ESD.

Results

In total, 15 proceduralist (11 gastroenterologists, 4 surgeons) performed 39, 206 elective colonoscopies from 2012 to 2022. The baseline characteristics of patients, year and procedure sessions are similarly distributed between the early and late groups.
Multivariant analysis found significant associations between late procedures and lower adenoma detection rates, polyp detection rates and SSL detection rates. After adjusting for age, gender, proceduralist, year, morning or afternoon procedure, and bowel preparation quality, PDR, ADR and SDR remain 20-28% lower in late colonoscopies compared with early ones. We also found that age, gender, proceduralist, year and bowel preparation independently affected ADR in multivariant analysis. However, morning or afternoon ADRs did not significantly differ after adjusting for other variables. Proceduralist were found to be the only additional significant variable for SDR in multivariant analysis. There was no significant association between timing of procedures and major adverse events.

Conclusion

This is the largest single-centre study on operator fatigue and its effect on colonoscopy quality. Although the minimum standards for ADR was achieved, ‘late procedures’ have statistically significant lower ADR, PDR and SSLDR compared to ‘early procedures’. There was no difference in the complication rates between ‘early procedures’ and ‘late procedures’.
This study highlights the detrimental effect of fatigue in later procedures affecting the quality of colonoscopies and may be applicable in principal to other procedural based clinical work. Importantly, this may or perhaps will or is having an impact on patient safety, satisfaction, outcomes and clinical KPI’s for the operators and hospital administrators.

Disclosure

None

Introduction

Etiology of acute pancreatitis can be established in the majority of patients. However, in 25 % of cases it remains elusive. Biliary microlithiasis/sludge is detected in up to 75% of patients with idiopathic acute pancreatitis (IAP). As recurrent biliary pancreatitis can be prevented, the underlying etiology of IAP should be established. The aim of this multicentre retrospective study was to develop a machine learning-aided non-invasive prediction tool to guide clinicians in the selection of idiopathic acute pancreatitis patients to be referred to endosonography to establish etiology and allow treatment.

Aims & Methods

We retrospectively used routinely recorded clinical and laboratory parameters of 218 consecutive patients with confirmed acute pancreatitis admitted to our tertiary care hospital between 2015 and 2020. Patients who did not receive endosonography as part of the diagnostic work-up and whose pancreatitis episode could be adequately explained by other causes than biliary sludge and microlithiasis were excluded. We trained supervised machine learning classifiers using H2O.ai automatically selecting the best suitable predictor model to predict microlithiasis/sludge. The predictor model was validated in two independent retrospective cohorts from two tertiary care centers (TU Munich & University Medical Center Göttingen).

Results

28 categorized patients’ variables recorded at admission were identified to compute the predictor model with an accuracy of 0.84 [95% CI 0.791, 0.9185], positive predictive value of 0.84 and negative predictive value 0.80 in the identification cohort (218 patients). In the validation cohort, the robustness of the prediction model was confirmed with an accuracy of 0.76 [95% CI 0.673, 0.8347], positive predictive value of 0.76 and negative predictive value of 0.78 (117 patients).

Conclusion

We present a robust and validated machine learning-based predictor model consisting of routinely recorded lab work at admission that can predict biliary sludge and microlithiasis as cause of acute pancreatitis and select patients for EUS.

Clinical Case Summary

Case: W present a case of a 43-year-old man with hepatic cirrhosis complicated by hypertensive gastrointestinal bleeding, in a program to eradicate esophageal varices. One week after an elective endoscopic variceal ligation (EVL), he presented with fever, anorexia, pain in the dorsolumbar region, headaches, and psychomotor retardation. Subsequently, there was the appearance of focal motor seizures. The analyses showed C-reactive protein of 113 mg/L, without leukocytosis. Peripheral blood cultures were negative. A head computed tomography (CT) showed mild left parietal and occipital cortical hypodensities. Analysis of the cerebrospinal fluid was compatible with central nervous system (CNS) infection. Cerebral magnetic resonance revealed multiple supra and infratentorial rounded lesions, compatible with abscesses and ventriculitis. He started antibiotics with a meningeal dose. Hospitalization was complicated by SARS-COV 2 infection, so a chest CT was performed after 1 month of hospitalization, and was identified a mediastinal abscess with 5 cm with fistulization from the esophagus, compatible with iatrogenic esophageal perforation after EVL. Other possible causes of brain abscesses were excluded. He completed several weeks of antibiotic and parenteral nutrition, with normalization of the neurological status and resolution of brain lesions. About 1 month after targeted antibiotic treatment, he performed an endoscopy, revealing a deformed area in the distal esophagus but no evidence of an orifice or suppuration. Conclusion: Neurological manifestations in patients with liver cirrhosis are usually due to hepatic encephalopathy (HE). However, CNS infection, especially in patients who underwent recent procedures, such as EBL, should be considered in the differential diagnosis, given that early treatment influences the prognosis. Clinically, CNS infection can be very variable, however, it is important to be aware of atypical signs of HE, such as focal neurological deficits.

References

Krige JE, Bornman PC, Shaw JM, Apostolou C. Complications of endoscopic variceal therapy. S Afr J Surg. 2005 Nov;43(4):177-88, 190-4.

Disclosure

Nothing to disclosure

Clinical Case Summary

Ballon-occluded retrograde transvenous occlusion (BRTO) is a minimal invasive procedure to treat mainly the gastric varices but it may be used in ectopic varices as well. We report a case of 70years old male known to have Alcoholic liver disease (cirrhosis) with portal hypertension, presented with malena. He underwent an urgent Gastroscopy which showed GAVE (Gastric antral vascular ectasia) and Grade 1 varix not needing any therapy. Due to persistent malena and haemoglobin drop, CT mesenteric angiogram was performed which reported multiple enlarged varices in the abdomen with no active site of haemorrhage. Video capsule endoscopy was performed which showed small bowel varices with evidence of fresh blood. Unfortunately, the ultrasound liver showed thrombosis of portal vein. Due to portal vein thrombosis TIPSS (Transjugular intrahepatic porto systemic shunt) was not performed and MDT decision for BRTO (Balloon-occluded retrograde transvenous occlusion) was made which the patient underwent successfully.
BRTO is advantageous over TIPSS because this can be performed with poor hepatic reserve and with hepatic encephalopathy however it increases the risk of bleeding from oesiphageal varices and ascites. Gastro-renal shunts are the most sites for use of BRTO however, this procedure was successfully done in this case.
Based on literature review BRTO procedure has been successfully used in gastric varices.
I’ve found few cases reported with small bowel varices treated with BRTO.
Learning points:

1. Whether BRTO is superior to TIPPS for ectopic varices
2. Whether BRTO can be considered in ectopic varices in patients without portal vein thrombosis

References

https://www.sciencedirect.com/science/article/pii/S1930043317305022


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444869/#!po=0.806452

Disclosure

No conflict of interest

Introduction

The introduction of lumen-apposing metal stents (LAMSs) has revolutionized the field of therapeutic endoscopic ultrasound (EUS). In the last decade, its utilization for off-label indications has markedly increased, particularly among patients with surgically altered anatomy to establish access in the excluded segment of the gastrointestinal tract. Indications for anastomosis creation include EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE), EUS-directed transgastric intervention (EDGI), or endoscopic reversal of Roux-en-Y gastric bypass (RYGB) for specific indications (see below).

Aims & Methods

This study aims to evaluate the effectiveness and safety of LAMS in patients with surgically altered anatomy for EDGE, EDGI, and reversal of RYGB. We collected data on all LAMS procedures conducted in patients with surgically altered anatomy, between October 2019 and February 2024 at the University Hospital of Ghent.
We used our prospective LAMS database and retrieved missing data from retrospective analysis of the medical patient records. The main outcome data of interest were technical success, clinical success, and adverse events. Technical success was defined as a successful placement of LAMS in the desired position. Clinical success was defined as either successful endoscopic access to the intended excluded gastrointestinal segment or achievement of the intended therapeutic goal when RYGB reversal was necessary. Adverse events were classified according to the AGREE criteria.

Results

A total of 73 LAMS procedures were performed: 70 cases of EUS-guided gastro-gastrostomy in patients with RYGB and 3 cases of EUS-guided gastro-enterostomy in patients with hepaticojejunostomy. Indications for LAMS procedures included 55 (75.3%) cases of EDGE, 13 (17.8%) cases of EDGI (such as gastroduodenoscopy and EUS), and 5 (6.8%) cases of RYGB reversal. Reversal of RYGB was required for one cachectic patient due to metastatic cholangiocarcinoma, three patients with hyperinsulinemic hypoglycemia, and one patient with therapy-resistant small intestinal bacterial overgrowth (SIBO).
The overall technical and clinical success rates were very high at 97.3% and 95.9%, respectively. Adverse events were observed in 11 out of 73 (15.1%) cases, including 7 (9.6%) minor events (AGREE score < 3) and 4 (5.5%) major events (AGREE score ≥ 3). Major events included stent migration (N=1), persistent fistula (N=2), and respiratory desaturation (N=1). All events could be successfully managed, and there were no procedure-related deaths. In 69.9% of cases, our method involved a dual-step approach, strategically implemented to await fistula maturation and reduce the risk of perforation. The median LAMS dwell time was 38 days (range 7, 431). LAMS was removed in 72.6% of the cases. Loss of LAMS patency occurred in 1 out of 73 (1.4%) cases and was endoscopically managed.

Conclusion

In conclusion, our study demonstrates that EUS-GG and EUS-GE offer an effective and safe approach to create anastomoses between gastrointestinal (GI) segments when performed by experts. With high technical (97.3%) and clinical (95.9%) success rates, LAMS proves beneficial for accessing excluded GI segments and reversing RYGB. Adverse events (15.1%) were mostly minor and manageable, with no procedure-related mortality. The extended patency duration and low re-intervention rate highlight LAMS as a minimally invasive and durable option in therapeutic endoscopic ultrasound procedures. Further prospective studies are required.