Updated evidence on epidemiology, diagnosis, and treatment for colonic diverticular bleeding

Since 2020, multiple large-scale studies (CODE BLUE-J) in Japan have accelerated the accumulation of evidence on colonic diverticular bleeding (CDB). This review summarizes the latest findings regarding CDB epidemiology and endoscopic hemostasis. Recent data show that CDB has become the most common cause of lower gastrointestinal bleeding in Japan, driven by an aging population and the increased use of antithrombotic medications. Although 70%-90% of patients achieve spontaneous hemostasis, rebleeding occurs in up to 35% of cases within 1 year. Despite an overall mortality rate of < 1%, patients with CDB can present with hypovolemic shock and may require urgent intervention. There are no effective pharmacological treatments for controlling CDB. Therefore, endoscopic therapy plays a crucial role in its management. Based on available evidence, both clipping and endoscopic band ligation are considered effective initial treatments. Recent studies indicate that direct clipping reduces early rebleeding compared with indirect clipping, while endoscopic band ligation achieves lower rebleeding rates (13%-15%) than clipping. The choice between direct clipping and endoscopic band ligation depends on the diverticulum location and the presence of active bleeding. Newer techniques, such as over-the-scope clip and self-assembling peptide application, have shown potential, but require further study. The detection of the bleeding source remains challenging because accurate identification is essential for successful hemostasis. Additional research is needed to refine the endoscopic diagnostic and therapeutic techniques, prevent rebleeding, and improve patient outcomes.

Chronic pancreatitis

Chronic pancreatitis is a progressive fibroinflammatory disease primarily caused by a complex interplay of environmental and genetic risk factors. It might result in pancreatic exocrine and endocrine insufficiency, chronic pain, reduced quality of life, and increased mortality. The diagnosis is based on the presence of typical symptoms and multiple morphological manifestations of the pancreas, including pancreatic duct stones and strictures, parenchymal calcifications, and pseudocysts. Management of chronic pancreatitis consists of prevention and treatment of complications, requiring a multidisciplinary approach focusing on lifestyle modifications, exocrine insufficiency, nutritional status, bone health, endocrine insufficiency, pain management, and psychological care. To optimise clinical outcomes, screening for complications and evaluation of treatment efficacy are indicated in all patients with chronic pancreatitis.

Role of endoscopic ultrasound as a predictor of histological healing in ulcerative colitis

BACKGROUND

Ulcerative colitis (UC) is a chronic inflammatory bowel disease with rising global prevalence.Histological healing (HH) is a key treatment target associated with better long-term outcomes. Although endoscopic ultrasound (EUS) is known to be related to both clinical and endoscopic activity in UC, its role in defining HH remains unclear. Therefore, this study was aimed at investigating the association between EUS and histological activity (HA), as well as the predictive potential of EUS for HH.

METHOD

In this cross-sectional analysis, 68 UC adults underwent EUS and colonoscopy with biopsies. We used the Mayo Endoscopic Score (MES) for endoscopic activity, the Nancy Index (NI) for biopsy grading, and the Endoscopic Ultrasound-Ulcerative Colitis (EUS-UC) score for EUS analysis, defining endoscopic remission as MES ≤ 1 and HH as NI ≤ 1.A receiver operating characteristic (ROC) curve was employed to evaluate the ability of the indices to predict HH.

RESULTS

Totally 23 patients (33.80%) achieved HH, while 45 (66.20%) showed HA. The EUS-UC scores were significantly lower in the HH group (p < 0.001) and correlated strongly with NI (ρ = 0.73). EUS-UC score was an independent risk factor for HH (adjusted OR = 1.918, 95% CI: 1.195-3.080, p = 0.007). The EUS-UC score demonstrated a strong predictive value for HH, with an AUC of 0.840, a sensitivity of 75.56%, and a specificity of 78.26%.

CONCLUSION

The EUS-UC score has a significant correlation with histological outcomes and shows strong potential as a reliable, invasive predictor of HH in UC, with implications for improved disease monitoring.

Development and validation of an integrated model for the diagnosis of liver cirrhosis with portal vein thrombosis combined with endoscopic characters and blood biochemistry data: a retrospective propensity score matching (PSM) cohort study

BACKGROUND

Liver cirrhosis complicated by portal vein thrombosis (PVT) is a fatal complication with no specific manifestations but often misdiagnosed, it crucially increases the mortality worldwide. This study aimed to identify risk factors and establish a predictive model for diagnosis of venous thrombosis clinical by routine blood tests and endoscopic characteristics.

METHODS

Patients from Gansu Provincial Hospital from October 2019 to December 2023 were enrolled. The retrospective modelling cohort was screened by propensity score matching (PSM) at a 1:1 ratio from the baseline characteristics before endoscopic diagnosis. Variables were collected from blood test and endoscopic signs using machine learning method (ML). Logistic regression determined risk factors. The predictive performance was evaluated by receiver operation curve (ROC), calibration curve, clinical decision analysis (DCA) and influence curve (CIC). Furthermore, external cohort was used for validation, an online nomogram was established.

RESULTS

A total of 1,058 patients were enrolled, and 470 patients were included after PSM 1: 1. The model identified 7 factors, including splenectomy, blood urea nitrogen (BUN), serum sodium, activated partial thromboplastin time (APTT), thrombin time (TT), D-dimer, and degree of oesophageal varices. The area under the curve (AUC) was 0.907 (95% CI, 0.877-0.931). The calibration curve, decision and clinical impact curves showed the model demonstrated a good predictive accuracy and clinical benefits. The validation got an AUC of 0.890 (95% CI, 0.831-0.934), A nomogram tool was finally established for application.

CONCLUSION

Blood test combined endoscopic characters could preliminarily predict the liver cirrhosis with portal vein thrombosis for cirrhotic patients undergoing endoscopic examination.

Risk factors for hepatocellular carcinoma: an umbrella review of systematic review and meta-analysis

BACKGROUND

Numerous meta-analyses have identified various risk factors for hepatocellular carcinoma (HCC), prompting a comprehensive study to synthesize evidence quality and strength.

METHODS

This umbrella review of meta-analyses was conducted throughout PubMed, EMBASE, Web of Science, and Cochrane Database of Systematic Reviews. Evidence strength was evaluated according to the evidence categories criteria.

RESULTS

We identified 101 risk factors throughout 175 meta-analyses. 31 risk factors were classified as evidence levels of class I, II, or III. HBV and HCV infections increase HCC risk by 12.5-fold and 11.2-fold, respectively. These risks are moderated by antiviral treatments and virological responses but are exacerbated by higher HBsAg levels, anti-HBc positivity, and co-infection. Smoking, obesity, non-alcoholic fatty liver disease, diabetes, low platelet, elevated liver enzymes and liver fluke infection increase HCC risk, while coffee consumption, a healthy diet, and bariatric surgery lower it. Medications like metformin, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), aspirin, statins, and selective serotonin reuptake inhibitors reduce HCC risk, while acid suppressive agents, particularly proton pump inhibitors, elevate it. Blood type O reduces the risk of HCC, while male gender and older age increase the risk.

CONCLUSIONS

HBV and HCV are major HCC risk factors, with risk mitigation through antiviral treatments. Lifestyle habits such as smoking and alcohol use significantly increase HCC risk, highlighting the importance of cessation. Certain drugs like aspirin, statins, GLP-1 RAs, and metformin may reduce HCC occurrence, but further research is needed to confirm these effects.

Applying machine learning to predict bowel preparation adequacy in elderly patients for colonoscopy: development and validation of a web-based prediction tool

BACKGROUND

Adequate bowel preparation is crucial for effective colonoscopy, especially in elderly patients who face a high risk of inadequate preparation. This study develops and validates a machine learning model to predict bowel preparation adequacy in elderly patients before colonoscopy.

METHODS

The study adhered to the TRIPOD AI guidelines. Clinical data from 471 elderly patients collected between February and December 2023 were utilized for developing and internally validating the model, while 221 patients' data from March to June 2024 were used for external validation. The Boruta algorithm was applied for feature selection. Models including logistic regression, light gradient boosting machines, support vector machines (SVM), decision trees, random forests, and extreme gradient boosting were evaluated using metrics such as AUC, accuracy, sensitivity, and specificity. The SHAP algorithm helped rank feature importance. A web-based application was developed using the Streamlit framework to enhance clinical usability.

RESULTS

The Boruta algorithm identified 7 key features. The SVM model excelled with an AUC of 0.895 (95% CI: 0.822-0.969), and high accuracy, sensitivity, and specificity. In external validation, the SVM model maintained robust performance with an AUC of 0.889. The SHAP algorithm further explained the contribution of each feature to model predictions.

CONCLUSION

The study developed an interpretable and practical machine learning model for predicting bowel preparation adequacy in elderly patients, facilitating early interventions to improve outcomes and reduce resource wastage.

Comparison of standard vs auxiliary (contrast or elastography) endoscopic ultrasound-guided fine needle aspiration/biopsy in solid pancreatic lesions: A meta-analysis

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/B) is the most common modality for tissue acquisition from pancreatic masses. Despite high specificity, sensitivity remains less than 90%. Auxiliary techniques like elastography and contrast-enhanced EUS may guide tissue acquisition from viable tumor tissue and improve the diagnostic outcomes theoretically. However, data regarding the same have shown conflicting results.

AIM

To compare the diagnostic outcomes of auxiliary-EUS-FNA/B to standard EUS-FNA/B for pancreatic lesions.

METHODS

The electronic databases of MEDLINE, EMBASE, and Scopus were searched from inception to February 2024 for all relevant studies comparing diagnostic outcomes of auxiliary-EUS-FNA/B to standard EUS-FNA/B for pancreatic lesions. A bivariate hierarchical model was used to perform the meta-analysis.

RESULTS

A total of 10 studies were identified. The pooled sensitivity, specificity, and area under the receiver-operated curve (AUROC) for standard EUS-FNA/B were 0.82 (95%CI: 0.79-0.85), 1.00 (95%CI: 0.96-1.00), and 0.97 (95%CI: 0.95-0.98), respectively. The pooled sensitivity, specificity, and AUROC for EUS-FNA/B with auxiliary techniques were 0.86 (95%CI: 0.83-0.89), 1.00 (95%CI: 0.94-1.00), and 0.96 (95%CI: 0.94-0.98), respectively. Comparing the two diagnostic modalities, sensitivity [Risk ratio (RR): 1.04, 95%CI: 0.99-1.09], specificity (RR: 1.00, 95%CI: 0.99-1.01), and diagnostic accuracy (RR: 1.03, 95%CI: 0.98-1.09) were comparable.

CONCLUSION

Analysis of the currently available literature did not show any additional advantage of EUS-FNA/B with auxiliary techniques for pancreatic solid lesions over standard EUS-FNA/B. Further randomized studies are required to demonstrate the benefit of auxiliary techniques before they can be recommended for routine practice.

The Role of Stereotactic Body Radiation Therapy in the Outcomes of Intrahepatic Recurrent Small Hepatocellular Carcinoma

Background and aim

To retrospectively evaluate the role of stereotactic body radiation therapy (SBRT) played for the outcomes of intrahepatic recurrent small hepatocellular carcinoma (HCC).

Methods

We collected 51 intrahepatic recurrent ≤5 cm small HCC patients between January 2016 and December 2021. SBRT was given as 4-5 fractions with 32.5-50Gy. The baseline data of the patients and the radiotherapy strategy data were collected and survival analyses were performed among these factors. The outcomes comprised overall survival (OS), freedom from local progression (FFLP), and progression-free survival (PFS), with the 95% confidence interval (95%CI). The follow-up time was calculated from the date of the SBRT to the date of the last follow-up communication, hospitalization, or death. Survival analysis was conducted by the Kaplan-Meier methods and log-rank test.

Results

The median follow-up time was 48 months (range: 4.8-90). The 1-year, 3-year, and 5-year OS rates of the overall cohort were 95.9% (95%CI: 0.905-1.000), 84.9% (95%CI: 0.751-0.959) and 69.1% (95%CI: 0.553-0.862), respectively. The 1-year, 3-year, and 5-year FFLP rates of the overall cohort were 97.5% (95%CI: 0.928-1.000), 82.0% (95%CI: 0.697-0.965), and 72.8% (95%CI: 0.578-0.918), respectively. The 1-year, 3-year, and 5-year PFS rates of the overall cohort were 85.7% (95%CI: 0.758-0.970), 43.4% (95%CI: 0.296-0.635), and 27.3% (95%CI: 0.149-0.498), respectively. The 5-year FFLP rate of lesions less than 2 cm [72.5% (95%CI: 0.52-1)] and those 2-5 cm [71.9% (95%CI: 0.514-0.976)] were similar. We suggested that the lesions received 45Gy/50Gy with 5 fractions were associated with a higher 5-year FFLP rate [74.6% (95%CI: 0.57-0.976)] than 40Gy/5F [40.0% (95%CI: 0.137-1)].

Conclusion

We found SBRT was effective in patients with lesion size of 2-5 cm, with similar results in those with tumor size of 0-2 cm. We suggested that the lesions received over 85.5Gy of biological effective dose with α/β = 10Gy were associated with a higher FFLP.

Pancreatic cancer precursor lesions - Can immunotherapy prevent progression into pancreatic ductal adenocarcinoma?

Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest cancers, with a 5-year survival rate of only 12.5 %. Early detection of PDAC or addressing risk factors for PDAC development are ways to improve outcomes. PDAC can arise from precursor lesions, including pancreatic intraepithelial neoplasia (PanIN), intraductal papillary mucinous neoplasm (IPMN), and less frequent, mucinous cystic neoplasm (MCN), and other rare precursor variants. High-risk precursor lesions harbor a substantial chance of evolving into PDAC. Such lesions can often be found in resected PDAC specimens adjacent to the cancer. Unfortunately, recognizing precursor lesions that need to be resected is often tricky, and resections frequently end in major surgical interventions. Thus, better ways to handle precursor lesions are desperately needed. We mapped the immune microenvironments (IMEs) of PanINs, IPMNs, and MCNs on a cellular level using multiplex immunofluorescence and computational imaging technology and compared the findings to PDACs and normal pancreatic tissues. We found distinct and potentially targetable mechanisms of immunosuppression between the two main precursor lesions, PanIN and IMPN. Immunosuppression in IPMNs seems partly mediated by programmed cell death protein 1 ligand (PD-L1) expression on antigen-presenting cells (APCs). By contrast, elevated numbers of regulatory T cells (Tregs) seem to be key players in the immunosuppression of PanINs. Thus, treating high-risk IPMNs with anti-PD-1 and high-risk PanINs with agents targeting Tregs, such as anti-lymphocyte associated protein 4 (anti-CTLA-4) antibodies, could reverse their immunosuppressive state. Reversal of immunosuppression will restore immunosurveillance and eventually prevent progression into PDAC. We also review relevant published and ongoing non-surgical treatment approaches for high-risk IPMNs and PanINs.

Metabolic dysfunction-associated steatotic liver disease (MASLD) in children with obesity: An Obesity Medicine Association (OMA) and expert joint perspective 2025

Introduction

This Obesity Medicine Association (OMA) Expert Joint Perspective examines steatotic liver disease (SLD), which is composed of metabolic dysfunction-associated steatotic liver disease (MASLD), and metabolic dysfunction-associated steatohepatitis (MASH) in children with obesity. The prevalence of obesity is increasing, rates have tripled since 1963 from 5 % to now 19 % of US children affected in 2018. MASLD, is the most common liver disease seen in children, can be a precursor to the development of Type 2 Diabetes (T2DM) and is the primary reason for liver transplant listing in young adults. We must be vigilant in prevention and treatment of MASLD in childhood to prevent further progression.

Methods

This joint clinical perspective is based upon scientific evidence, peer and clinical expertise. The medical literature was reviewed via PubMed search and appropriate articles were included in this review. This work was formulated from the collaboration of eight hepatologists/gastroenterologists with MASLD expertise and two physicians from the OMA.

Results

The authors who are experts in the field, determined sentinel questions often asked by clinicians regarding MASLD in children with obesity. They created a consensus and clinical guideline for clinicians on the screening, diagnosis, and treatment of MASLD associated with obesity in children.

Conclusions

Obesity and the comorbidity of MASLD is increasing in children, and this is a medical problem that needs to be addressed urgently. It is well known that children with metabolic associated chronic disease often continue to have these chronic diseases as adults, which leads to reduced life expectancy, quality of life, and increasing healthcare needs and financial burden. The authors of this paper recommend healthy weight reduction not only through lifestyle modification but through obesity pharmacotherapy and bariatric surgery. Therefore, this guidance reviews available therapies to achieve healthy weight reduction and reverse MASLD to prevent progressive liver fibrosis, and metabolic disease.

Diagnostic accuracy and influencing factors of microprobe endoscopic ultrasound for gastrointestinal subepithelial lesions: a multicenter retrospective study

BACKGROUND

Microprobe endoscopic ultrasonography (MEUS) has been widely adopted in primary hospitals due to its affordability, ease of use, and simple operation. This study aims to assess the diagnostic accuracy of MEUS in classifying gastrointestinal subepithelial lesions (SELs), identify key influencing factors, and explore strategies for improvement.

METHODS

A retrospective analysis was conducted on 855 patients with histopathologically confirmed SELs across five Chinese hospitals. The overall diagnostic accuracy (DA) of MEUS for SELs was calculated. Independent factors were identified using univariate and multivariate logistic regression analyses, followed by subgroup analysis.

RESULTS

Among 896 lesions across 31 SEL types, the overall DA was 70.31%. Non-gastrointestinal stromal tumor (GIST) and non-neuroendocrine tumor (NET) lesions, along with gastric location, were identified as risk factors for lower diagnostic accuracy, while rectal location was protective. In the subgroup analysis, gastric leiomyomas had a DA of 9.85% with 99.17% incorrectly classified as GISTs, compared to 94.78% for gastric GISTs, 84.24% for gastric NETs, and 31.2% for other lesions. Lesions with inhomogeneous echoes were 20 times more likely than those with homogeneous echoes to be diagnosed as gastric GISTs compared to gastric leiomyoma. Additionally, the inhomogeneous echo patterns of gastric GISTs were characterized by hyperechogenic spots in 93.67%, marginal halos in 18.99%, and cystic changes in 13.92%.

CONCLUSION

MEUS is effective for classifying SELs, although differentiating between gastric GISTs and leiomyomas remains challenging. Improved assessment of echo heterogeneity and expanded knowledge of atypical and rare cases may enhance diagnostic accuracy.

Diagnostic challenges of inflammatory submucosal tumor-like lesions: a multicenter propensity score-matching analysis

BACKGROUND

Gastrointestinal submucosal tumors (SMTs) are frequently encountered in clinical practice, with diverse etiologies and overlapping endoscopic features. Inflammatory SMT-like lesions (I-SMTLs), though rare and benign, mimic SMTs endoscopically but are fundamentally inflammatory. Limited research exists on their specific diagnostic characteristics.

METHODS

This multicenter retrospective study analyzed 59 I-SMTLs among 1,226 pathologically confirmed SMTs from five hospitals in China. The diagnostic efficacy of endoscopic ultrasound (EUS) for I-SMTLs was assessed, and comparison with non-inflammatory SMT-like lesions (non-I-SMTLs) was made using propensity score matching (PSM) balanced for sex, age, lesion location and size. Correlation between endoscopic and pathological characteristics were quantified using Cramer's V coefficient.

RESULTS

I-SMTLs accounted for 4.81% (59/1,226) of SMTs, with 98.31% (58/59) measuring under 2 cm. EUS demonstrated low sensitivity (3.39-4.00%) and a high misdiagnosis rate (96.61%) for I-SMTLs, with over 55% misdiagnosed as potentially malignant and 15% remaining inconclusive. In the PSM cohort (59 I-SMTLs, 118 non-I-SMTLs), I-SMTLs were more frequently located in submucosa (71.19% vs. 42.37%), exhibited mixed-echoic category (18.64% vs. 1.69%), heterogeneous echogenicity (62.71% vs. 21.19%) and unclear boundaries (42.37% vs. 13.56%). Correlation analysis showed cases with smooth muscle hyperplasia in pathology were more likely to arise from the muscularis propria or muscularis mucosae (Cramer's V = 0.490), and cases with fibrous tissue alterations were more likely to exhibit mixed or hyperechoic patterns (Cramer's V = 0.545) and heterogeneous echotexture (Cramer's V = 0.336) on EUS.

CONCLUSIONS

I-SMTLs pose significant diagnostic challenges. Distinguishing EUS features, including submucosal location, mixed-echoic patterns, heterogeneous textures, and unclear boundaries, may improve diagnostic accuracy and facilitate appropriate clinical decision-making.

Deficiency of β-arrestin2 ameliorates MASLD in mice by promoting the activation of TAK1/AMPK signaling

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a liver manifestation of metabolic syndrome characterized by excessive hepatic lipid accumulation and lipid metabolism disorders. It has become the most common chronic liver disease worldwide. β-arrestin2 is a multifunctional scaffold protein that is among the most important regulatory molecules, and it exerts key roles in regulating various cellular processes, such as immune response, cellular collagen production, and inflammation. In the current study, we aimed to explore the function of β-arrestin2 in the development and progression of MASLD. Firstly, we observed that the expression of β-arrestin2 was upregulated in liver samples from patients with MASLD. Then, the western diet (WD) combined with CCl4 injection-induced MASLD was established in wild-type mice, and showed that liver β-arrestin2 expression was also gradually increased, and positively correlated with the degree of lipid metabolism disorder during MASLD progression. Ulteriorly, β-arrestin2 knockout (Arrb2 KO) mice were utilized to induce the MASLD model and found that β-arrestin2 deficiency significantly ameliorated lipid accumulation and inflammatory response in the liver of MASLD mice. Furthermore, the in vitro depletion and overexpression experiments showed that increased β-arrestin2 aggravated lipid accumulation via inhibiting the activation of the TAK1/AMPK pathway, which may be mediated by competitively binding to TAB1 with TAK1. These findings suggest that β-arrestin2 is essential to regulate intrahepatic lipid metabolism. Here, we provide a novel insight in understanding of the expression and function of β-arrestin2 in MASLD, demonstrating that it may be a potential therapeutic target for MASLD treatment.

Effect of sex on the outcomes of peroral endoscopic myotomy for the treatment of achalasia

BACKGROUND

Peroral endoscopic myotomy (POEM) has emerged as the first-line therapy for achalasia. However, large-scale studies which examine sex-related differences in symptoms and outcomes remain limited.

AIM

To evaluate the impact of sex on achalasia symptoms, diagnostic findings, and postoperative improvement following POEM.

METHODS

We conducted a retrospective review of achalasia patients who underwent POEM at a large center between 2010 and 2020, analyzing demographics and variables collected before, during, and after the procedure for both female and male cases.

RESULTS

Our study included 526 cases in total, with the female group experiencing more severe chest pain (P = 0.008). After stratifying age, we found that women aged 40 to 60 showed higher chest pain scores compared to their male counterparts. In female cases, the severity of dysphagia before POEM was lowest among those aged 60 and older (P = 0.033). Preoperatively, the integrated relaxation pressure (IRP) and resting lower esophageal sphincter pressure (LESP) were higher in the female group compared to the male group (P < 0.001 and P = 0.001, respectively). However, no differences in postoperative IRP and LESP were observed between two groups. The overall efficiency of POEM was 96.52%, with a significant improvement in chest pain scores noted in female cases (P = 0.043).

CONCLUSION

Sex may influence the severity and frequency of chest pain, with female cases exhibiting higher LESP and IRP compared to male cases. POEM is proven to be a safe and effective procedure for both sexes, with female cases potentially experiencing greater benefits.

Laparoscopic and Percutaneous Microwave Ablation for Hepatocellular Carcinoma-An Institutional Analysis of Complimentary Therapeutic Modalities

INTRODUCTION

Microwave ablation (MWA) is a locoregional thermoablative treatment for early HCC with equivalent outcomes to liver resection with reduced morbidity. Our study aimed to assess the oncological and perioperative outcomes of percutaneous and surgical MWA demonstrating their complementary utilization.

METHODS

All patients undergoing percutaneous (pMWA) and surgical (sMWA) MWA for HCC at St Vincent's Hospital in Melbourne, Australia between August 2011 and April 2023 were included.

RESULTS

140 microwave ablations occurred in 107 patients with a median follow-up of 37.1 months (range 2.4-105.9 months). There were 51 pMWA and 56 sMWA cases, of which 53 were undertaken laparoscopically. Surgical ablations had a higher BCLC stage, and due to more instances of multiplicity, sMWA delivered more ablations and energy per lesion. This was associated with longer procedural time (69.5 min vs. 45 min and p < 0.001) and postoperative length of stay (1 day vs. 2 days and p < 0.001). Clavien-Dindo III or more complications were no different between the groups (p = 0.404). Local recurrence was significantly higher in the percutaneous group (31.4% vs. 10.7% and p = 0.016), and multivariate analysis demonstrated that technique was a predictor of local recurrence (sMWA HR 0.22, 95% CI 0.08-0.65, and p = 0.006). The median disease-free survival was 3.0 years (95% CI 2.6-NS) for sMWA and 1.7 years (95% CI 1.5-3.7) for pMWA, but the difference was not significant (p = 0.36). There were insufficient events to calculate median overall survival for each group; however, no differences were observed with an overall 5-year survival estimate of 0.64 (95% CI 0.54-0.77 and p = 0.86).

CONCLUSION

pMWA and sMWA are effective locoregional therapies for HCC. sMWA has the ability to deliver more energy per ablation with reduced local recurrence. However, overall survival is unaffected using the approach and both modalities should be used in a complimentary manner.

Artificial intelligence and colorectal neoplasia detection performances in patients with positive fecal immunochemical test: Meta-analysis and systematic review

OBJECTIVES

The combination of fecal immunochemical test (FIT) followed by colonoscopy has established itself as one of the preferred population-based screening strategies. Despite extensive exploration of various techniques and technologies, their impact on adenoma detection rate has shown inconsistency across studies in this specific setting "FIT+ population." We aimed to assess the impact of the computer-aided detection (CADe) system in all randomized trials focused on this subpopulation.

METHODS

We searched MEDLINE, EMBASE, and Scopus databases until September 2023 for randomized controlled trials reporting diagnostic accuracy of CADe systems for detection of colorectal neoplasia. The primary outcome was pooled adenoma detection rate, and secondary outcomes were adenoma per colonoscopy, advanced adenoma per colonoscopy, serrated lesions, and nonneoplastic per colonoscopy.

RESULTS

Ten randomized trials on 5421 patients were included. Adenoma detection rate was higher in the CADe group than in the standard colonoscopy group (0.62 vs. 0.52; relative risk 1.19; 95% confidence interval 1.08-1.31). CADe also resulted in higher detection performances of both adenomas (incidence rate ratio 1.16; 95% confidence interval 1.09-1.24) and serrated lesions (incidence rate ratio, 1.20; 95% confidence interval 1.05-1.38) at per-polyp analysis. No differences were found for advanced adenomas between the groups. On the other hand, more nonneoplastic polyps were removed in the CADe than the standard group (0.45 vs. 0.34; mean difference 0.06; P = 0.026) in a comparable inspection time.

CONCLUSIONS

The use of CADe during colonoscopy results in an increased detection of adenomas, and serrated lesions, in a FIT+ setting. The impact on advanced adenomas was not significant. Higher rates of unnecessary removal of nonneoplastic polyps were also reported.

Comparison of 12- and 15-mm endoscopic papillary large balloon dilation combined with a limited endoscopic sphincterotomy for large bile duct stones: A propensity score-matched analysis

BACKGROUND AND STUDY AIMS

Endoscopic papillary large balloon dilation (EPLBD) combined with endoscopic sphincterotomy (EST) has been increasingly used to remove large common bile duct (CBD) stones. However, the clinical outcomes of stone extraction have rarely been investigated in regard to the size of the balloon. The aim of this study was to assess the short- and long-term outcomes of 12- and 15-mm EPLBD with a limited EST for large CBD stones.

PATIENTS AND METHODS

Patients without prior endoscopic retrograde cholangiopancreatography (ERCP) who received 12- or 15-mm EPLBD in combination with a limited EST for large CBD stones at our center between January 2013 and December 2020 were recruited. Matched pairs with 12- and 15-mm EPLBD were generated.

RESULTS

A total of 161 patients were included, with 50 patients successfully matched in each group. The total procedure time (36.8 min vs. 47.3 min, p = 0.003) and the tone removal time (30.5 min vs. 39.2 min, p = 0.008) were significantly lower in the matched 15-mm EPLBD group, while the initial and overall stone removal success rates were comparable between the two groups (p > 0.05). The matched 15-mm EPLBD group had a lower incidence of post-ERCP pancreatitis (PEP) compared to the matched 12-mm EPLBD group (2.0 % vs. 16.0 %, p = 0.031). The cumulative long-term biliary complications were not statistically different between the two groups (log-rank test p = 0.612).

CONCLUSION

15-mm EPLBD combined with a limited EST shortened the procedure time and reduced the incidence of PEP without increasing long-term biliary complications compared to 12-mm EPLBD combined with a limited EST.

Novel pH-responsive folate conjugated chitosan and thiolated carboxymethyl cellulose based nanoparticles: potential approach for site-specific targeting in colon cancer treatment

The study objective was to develop folate decorated chitosan (CHT-FA) by the carbodiimide-mediated process to utilize the overexpressed folate receptors in the treatment of colon cancer. The substitution degree of FA to CHT was 1.4 %. FTIR and H1NMR ensured the successful conjugation of FA with CHT. Thermal analysis and XRD demonstrated the thermal stability and amorphous nature of CHT-FA after conjugation. Thiolation of carboxymethyl cellulose, having a 1612.35 μmol/g thiol group, was achieved via oxidation followed by reductive amination. CHT-FA and thiolated carboxymethyl cellulose (CMC-SH) were utilized in the development of nanoparticles with eudragit S100 coating (EU-FU-CHT-FA/CMC-SH NPs) for targeted delivery to the colon. The fabricated NPs demonstrated a higher release pattern at 7.4 pH after <5 % release at 1.2 pH. CHT-FA/CMC-SH NPs showed enhanced mucoadhesion time by up to 237 min. Furthermore, compared to the FU solution, the MTT analysis showed that FU-CHT-FA/CMC-SH NPs had a more cytotoxic effect and increased cellular uptake in the Caco-2 cell line via the folate receptor-facilitated endocytosis process along with the consequence of thiolation which prevents closer of tight junction, resulting in enhanced cellular absorption. These findings support the potential of the developed NPs as a tumor-targeted therapeutic delivery.

Impact of endoscopic ultrasound-guided biliary drainage on the management of difficult biliary cannulation in patients with distal malignant biliary obstruction

Biliary drainage in patients with distal malignant biliary obstruction (DMBO) carries a higher risk of difficult biliary cannulation (DBC) during endoscopic retrograde cholangiopancreatography (ERCP). After the failure of standard cannulation, endoscopists may proceed with advanced cannulation techniques and/or with endoscopic ultrasound-guided biliary drainage (EUS-BD).This was a retrospective study of consecutive patients with DMBO and a dilated common bile duct (CBD; >12 mm) who underwent ERCP for endoscopic biliary drainage in four European centers. The rates of DBC, technical and clinical success, and procedure-related adverse events (AEs) were assessed. The predictive factors for AEs were also investigated through regression analysis. The EUS-BD approach was considered either as the first option after standard cannulation failure or as the final option after advanced cannulation failure.1016 patients with DMBO were included in the study, with 524 (51.6%) matching the definition of DBC. Clinical success was achieved in 956 patients (94.1%). Procedure-related AEs were experienced by 167 patients (16.4%). Patients with DBC had a higher risk of AEs (P=0.003); however, patients undergoing "early" EUS-BD showed a risk of AEs comparable with those managed with standard cannulation (P=0.38). An attempt at any advanced cannulation technique was independently associated with the occurrence of AEs (P=0.001).The risk of AEs is higher in patients with DMBO and DBC, this appears to be mainly related to the advanced cannulation techniques. In patients with a dilated CBD (>12 mm), "early" EUS-BD may minimize the risk of AEs.

Contrast-enhanced ultrasonography combined with microbubbles for uterine disorders: Current trends and future perspectives

Uterine disorders, including fibroids, polyps, and carcinomas, represent significant health concerns for women. Conventional diagnostic methods, including ultrasound and magnetic resonance imaging, often lack the sensitivity required to accurately delineate and evaluate these lesions. Consequently, there is a growing need for advanced imaging techniques to enhance both diagnostic precision and therapeutic decision-making. Standard imaging modalities typically provide low resolution, limiting their effectiveness in evaluating uterine pathology and determining optimal treatment strategies. In this context, microbubbles combined with contrast-enhanced ultrasonography offer a promising solution. This technique enhances the visualization of vascular patterns and tissue perfusion, facilitating a more accurate assessment of uterine lesions. Contrast-enhanced ultrasonography is less invasive, is more cost-effective, and offers real-time evaluation of vascular characteristics, making it a valuable tool for diagnosing uterine abnormalities. This review explores the clinical utility of contrast-enhanced ultrasonography with microbubbles in uterine diseases, focusing on its diagnostic accuracy, comparison with traditional imaging techniques, and its potential to improve the management of uterine pathology.

Analysis of the Efficacy of Invasive Mechanical Ventilation in ICU Patients with Severe Heart Failure

In order to study the clinical treatment effect and analyze the main clinical effects of invasive mechanical ventilation in ICU patients with severe heart failure, this paper proposes a efficacy analysis method based on invasive mechanical ventilation for ICU patients with severe heart failure. This study used a retrospective analysis to select 50 patients with severe heart failure admitted to the ICU of a certain hospital from January 2021 to March 2022 as the research subjects, divided into a control group and an observation group. The control group received conventional treatment methods, while the observation group received invasive mechanical ventilation treatment in addition to conventional treatment, and a nursing quality index system was constructed to verify the feasibility and scientificity of the treatment plan. The research results showed that the treatment effectiveness rate of the observation group was 96%, significantly higher than the control group's 84%. In addition, the arterial oxygen saturation (SaO ₂) and partial pressure of oxygen (PaO ₂) in the observation group were significantly increased after treatment compared to the control group, while the partial pressure of carbon dioxide (PaCO ₂) was lower (P<0.05). In addition, in order to improve the comprehensiveness of the analysis, this study further explored the epidemiological characteristics of patients with severe heart failure, including the influence of age, complications (such as diabetes, hypertension, etc.), course characteristics and other factors on the treatment effect. At the same time, an in-depth analysis was conducted on the application strategies of invasive mechanical ventilation in the treatment of severe heart failure, including airway management, ventilator mode optimization, complication prevention, and nursing measures. In addition, this study compared the applicability of invasive and non-invasive mechanical ventilation in the treatment of severe heart failure patients and evaluated the impact of different mechanical ventilation strategies on patient prognosis. To sum up, this study shows that invasive mechanical ventilation can significantly improve the treatment effect of patients with severe heart failure in ICU, improve the oxygenation level and reduce carbon dioxide retention, while optimizing the quality of care and improving the survival rate. The conclusion of this study provides a reference for clinical practice and proposes exploration directions for further optimizing mechanical ventilation strategies in the future.

Characteristics and Outcomes of Hepatocellular Carcinoma in Patients with Autoimmune Hepatitis

BACKGROUND

The incidence of HCC in patients with autoimmune hepatitis (AIH) is low and, due to the paucity of data in the literature, a thorough characterization of these patients is missing.

AIM

To describe the main characteristics and outcome of patients with AIH and HCC.

METHODS

Among patients with HCC included in the Italian Liver Cancer (ITA.LI.CA) database during the period 2009-2022, we selected those with AIH, and we described their liver disease characteristics, modality of HCC diagnosis, tumor stage, treatment, and outcome.

RESULTS

Among 10,026 patients with HCC, we identified 23 patients (0.2%) with AIH (43.5% males, 69.6% aged > 65 years, 91.0% with cirrhosis). Fifteen patients (65.2%) had co-factors of liver disease [8 patients (34.8%) metabolic dysfunction-associated steatotic liver disease, 4 patients (17.4%) alcohol abuse, 3 patients (13.0%) AIH/Primary Biliary Cholangitis overlap syndrome]. Tumors diagnosed under surveillance (60.9%) were more frequently uninodular (85.7% vs 66.6%, p = 0.146) and Milan-in (85.7% vs 44.4%, p = 0.066) than those diagnosed outside surveillance. Treatment with curative intent was more frequent among patients under surveillance (78.6% vs 33.3%, p = 0.077). Median overall survival was 41.7 months and was remarkably longer in patients under surveillance than in those diagnosed outside surveillance (68.2 vs 27.4 months, p = 0.032).

CONCLUSION

AIH accounts for a minimal fraction of patients with HCC, and in most patients, risk co-factors for HCC are present. In patients with AIH, too, surveillance is associated with better tumor stage, higher access rate to potentially curative treatments, and improved survival.

Current status and trends in ERCP and post-ERCP pancreatitis in Japan: a nationwide observational study

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is indispensable for the management of biliary and pancreatic diseases but carries a high risk of post-ERCP pancreatitis (PEP). This study aimed to clarify the current status and temporal trends of ERCP and PEP in Japan, including preventive measures.

METHODS

We conducted a retrospective, population-based cohort study using the Diagnosis Procedure Combination database from April 1, 2016, to March 31, 2023. Trend analyses were performed for ERCP, PEP, nonsteroidal anti-inflammatory drugs (NSAIDs), and protease inhibitors. Additionally, factors associated with PEP and severe PEP were evaluated.

RESULTS

Among the 1,073,513 ERCP cases, PEP and severe PEP incidences were 85,212 (7.9%) and 4841 cases (0.5%), respectively. The mortality rate was 0.5% for severe PEP and 0.2% for non-severe cases. The number of ERCP procedures and the proportion of therapeutic ERCP increased over time. The incidence of PEP declined from 9.1% in the fiscal year 2016-2017 to 6.4% in the fiscal year 2022, while the incidence of severe PEP decreased from 0.5 to 0.33% over the same period. The usage rate of rectal NSAIDs increased from 16.4 to 27.6%, whereas that of protease inhibitors decreased from 70.5 to 53.5%. The administration of rectal NSAIDs at doses of 20-25 mg and 50 mg was associated with a reduced risk of severe PEP.

CONCLUSIONS

The number of ERCP procedures and the proportion of therapeutic ERCP have increased, whereas the incidences of PEP and severe PEP have decreased. Rectal NSAIDs may prevent the progression of PEP to severe disease.

Appropriate use of tissue sampling and somatostatin receptor PET imaging in the diagnosis of pancreatic neuroendocrine tumors: results of an International Delphi Consensus

BACKGROUND

Current guidelines lack clarity regarding the appropriate use of preoperative ultrasound-guided (EUS) biopsy and receptor positron emission tomography (SSTR PET) imaging for pancreatic neuroendocrine tumors (PNETs). This study aims to reach expert consensus on the optimal sequencing of SSTR PET and EUS biopsy in the diagnostic workup and management of patients with suspected PNETs.

METHODS

A three-round modified Delphi process was used. A multidisciplinary panel of experts was recruited via snowball sampling. A set of 22 baseline statements pertaining to diagnostic workup, imaging, and biopsy was developed based on literature review and feedback obtained through a focus group. Survey rounds were conducted electronically and anonymously. A panel of international experts was asked to indicate whether they agreed, disagreed, or lacked the appropriate background to answer each statement. Of the 55 experts invited, 38 (69%) accepted to participate. Consensus was achieved with > 80% agreement.

RESULTS

Response rates were 97%, 100%, and 100% in rounds 1, 2, and 3, respectively. Following rounds 1 and 2, 29 final statements achieved consensus in the following three domains: diagnostic workup (15 statements), imaging (nine statements), and tissue sampling (five statements). Cronbach's alpha value, a measure of internal consistency, was 0.91 and 0.85 for rounds 1 and 2, respectively. The final set of statements achieved a 95% approval rate in round 3.

CONCLUSION

This international Delphi study provides expert consensus-based guidance on the appropriate use of EUS biopsy in the diagnostic workup of PNETs in the era of SSTR PET imaging.

Cytology of cystic lesions of the pancreas: Practical insights, pearls, and pitfalls

Pancreatic cyst fluid (PCF) specimens present significant interpretive challenges. Accurate preoperative diagnosis is essential for guiding patient management, as pancreatic cysts vary from benign to pre-malignant and malignant. Appropriate triage differentiates low-risk cysts requiring surveillance from high-risk cysts necessitating surgical resection, the latter of which have increased likelihood of progressing to or harboring invasive carcinoma. Optimal PCF assessment integrates radiological, cytological, biochemical, and molecular findings if available. Key biochemical markers such as carcinoembryonic antigen and glucose can improve the detection of neoplastic mucinous cysts. However, cytology remains the most specific modality for identifying high-risk cysts. Cytomorphologic interpretation is particularly challenging due to the scant cellularity and degenerative changes often present in these specimens. This review provides practical insights to improve the evaluation of pancreatic cysts, emphasizing the importance of a multidisciplinary approach and highlighting diagnostic pearls and common pitfalls to aid in accurate interpretation and optimal patient care.

Predictive Value of Radiographic Tumor Burden Score in Hepatocellular Carcinoma Within Milan Criteria After Microwave Ablation: Implications for Long-Term Outcomes and Treatment Planning

OBJECTIVE

This study aimed to investigate the predictive value of the radiographic tumor burden score (TBS) for long-term outcomes in hepatocellular carcinoma (HCC) patients meeting Milan criteria after microwave ablation (MWA) and to delineate its significance in guiding treatment planning.

METHODS

Retrospective analysis was conducted on clinical data from 198 HCC patients meeting Milan criteria, who underwent MWA at our hospital from January 2011 to December 2018. Using X-tile software, the optimal critical value of TBS was determined, leading to the categorization of patients into high- and low-TBS groups. Propensity score matching (PSM) was applied to balance covariates between these groups.

RESULTS

Before PSM, the 5-year overall survival (OS) rate and recurrence-free survival (RFS) rate in the high-TBS (47 cases) and low-TBS groups (151 cases) were 32.8% versus 59.7% (p = 0.033) and 23.4% versus 50.9% (p = 0.016), respectively. Following PSM, the 5-year OS rate and RFS rate in the high-TBS (44 cases) and low-TBS groups (95 cases) were 30.2% versus 64.1% (p = 0.011) and 21.9% versus 45.9% (p = 0.0059), respectively. Cox analysis identified high TBS and percutaneous microwave ablation (PMWA) as independent risk factors for OS and RFS. The stratified analysis revealed that the median RFS time for patients undergoing laparoscopic microwave ablation (LMWA) (20 cases) and PMWA (24 cases) in the high-TBS group (44 cases) was 45 and 10.5 months, respectively (p = 0.006).

CONCLUSION

TBS emerged as a robust predictor for the long-term outcomes of HCC within Milan criteria after MWA. A higher TBS was associated with a diminished long-term survival rate. Notably, among HCC patients meeting Milan criteria, those with TBS > 3 exhibited a prolonged median RFS time following LMWA compared to PWMA.

[Relevance of frozen section diagnostics in pancreatic surgery]

Frozen sections are performed in pancreatic surgery for three reasons: histopathological confirmation of previously unclear space-occupying lesions, determination of the extent of surgical resection in an operative exploration and for possible follow-up resections after previously carried out surgical resections. Overall, in the literature there are heterogeneous data with respect to an improvement in the prognosis of a secondary R0 resection by a repeat resection in comparison to a R1 resection. Nowadays, extended pancreatic resections including vascular resections are technically feasible and safe. Nevertheless, with respect to the precise radicality in the surgical procedure, all patient characteristics should be taken into consideration in addition to the histopathological diagnosis of the frozen sections.

Adverse events of 20-22G second-generation endoscopic ultrasound-guided fine-needle biopsy needles for solid lesions in the upper gastrointestinal tract and adjacent organs: Systematic review and meta-analysis

OBJECTIVES

Previous research has conducted meta-analyses on the diagnostic accuracy of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB). However, studies on adverse events (AEs) have been limited and sporadic and have included a highly diverse group of patients (with upper and lower gastrointestinal tract issues) and needles of varying sizes (19-22-25G). The purpose of this systematic review and meta-analysis was to determine the incidence of AEs related to the utilization of 20-22G second-generation EUS-FNB needles subsequent to puncture of the upper gastrointestinal tract and adjacent organs.

METHODS

We searched the PubMed, Embase, and SCIE databases from January 1, 2010, to December 31, 2023. The primary outcome was percentage of summary AEs. Subgroup analyses were based on needle type, needle size, and lesion site.

RESULTS

A total of 99 studies were included in the analysis, with 9303 patients. The overall AE rate for 20-22G second generation EUS-FNB needles in upper gastrointestinal EUS-FNB was 1.8% (166/9303), with bleeding being the most common AE at 44.0%. The percentages of pancreatitis, abdominal pain, and other AEs were 24.1%, 21.1%, and 10.8%, respectively. Patients undergoing hepatic EUS-FNB had the highest incidence of AEs at 14.0%, followed by submucosal lesions at 3.2% and pancreatic lesions at 2.6%.

CONCLUSION

EUS-FNB is a safe procedure with a relatively low risk of upper gastrointestinal AEs (1.8%) and no associated deaths. Postoperative bleeding and pancreatitis are the most common complications of EUS-FNB. Most AEs are mild and self-limiting in severity, and serious complications are very rare.

Socioeconomic inequalities in diagnostics, care and survival outcomes for hepatocellular carcinoma in Sweden: a nationwide cohort study

Background

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. This study evaluates how strongly socioeconomic factors associate with diagnostics, treatment, and survival among patients with HCC in Sweden.

Methods

All adult patients registered with a diagnosis of HCC in the Swedish quality register for liver cancer between 2011 and 2021 were included. Household income was classified as low (first quartile; poorest), medium (second or third quartile), or high (in fourth quartile; wealthiest) based on the overall distribution of household income across all household in Sweden. Outcomes included likelihood of diagnosis under surveillance, early-stage diagnosis (Barcelona Clinic Liver Cancer [BCLC] staging 0-A), and receipt of curative treatment (ablation, resection or liver transplantation), as well as mortality risk.

Findings

Among 5490 patients, a significant association was found between low household income and decreased likelihood of diagnosis while under surveillance (adjusted odds ratio [aOR] 0·63; 95% confidence interval [CI]: 0·50-0·80), early-stage diagnosis (aOR 0·58; 95% CI: 0·51-0·67), and curative treatment receipt (aOR 0·65; 95% CI: 0·50-0·85). After adjustments for all variables in the BCLC, other sociodemographic variables, comorbidities, and cirrhosis status, patients with low household income had an adjusted hazard ratio for mortality of 1·29 (95% CI: 1·15-1·45) compared to patients with high household income.

Interpretation

Socioeconomic disparities associate markedly with more advanced stage at HCC diagnosis, less curative treatment, and poorer survival in Sweden. Addressing these disparities through targeted public health interventions may improve HCC care and outcomes in socioeconomically disadvantaged populations.

Funding

The Swedish Cancer Society-Cancerfonden.

Predicting post-hepatectomy liver failure in patients with hepatocellular carcinoma: nomograms based on deep learning analysis of gadoxetic acid-enhanced MRI

OBJECTIVES

This study aimed to develop nomograms for predicting post-hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC), using deep learning analysis of Gadoxetic acid-enhanced hepatobiliary (HBP) MRI.

METHODS

This retrospective study analyzed patients who underwent gadoxetic acid-enhanced MRI and hepatectomy for HCC between 2016 and 2020 at two referral centers. Using a deep learning algorithm, volumes and signal intensities of whole non-tumor liver, expected remnant liver, and spleen were measured on HBP images. Two multivariable logistic regression models were formulated to predict PHLF, defined and graded by the International Study Group of Liver Surgery: one based on whole non-tumor liver measurements (whole liver model) and the other on expected remnant liver measurements (remnant liver model). The models were presented as nomograms and a web-based calculator. Discrimination performance was evaluated using the area under the receiver operating curve (AUC), with internal validation through 1000-fold bootstrapping.

RESULTS

The study included 1760 patients (1395 male; mean age ± standard deviation, 60 ± 10 years), with 137 (7.8%) developing PHLF. Nomogram predictors included sex, gamma-glutamyl transpeptidase, prothrombin time international normalized ratio, platelets, extent of liver resection, and MRI variables derived from the liver volume, liver-to-spleen signal intensity ratio, and spleen volume. The whole liver and the remnant liver nomograms demonstrated strong predictive performance for PHLF (optimism-corrected AUC of 0.78 and 0.81, respectively) and symptomatic (grades B and C) PHLF (optimism-corrected AUC of 0.81 and 0.84, respectively).

CONCLUSION

Nomograms based on deep learning analysis of gadoxetic acid-enhanced HBP images accurately stratify the risk of PHLF.

KEY POINTS

Question Can PHLF be predicted by integrating clinical and MRI-derived volume and functional variables through deep learning analysis of gadoxetic acid-enhanced MRI? Findings Whole liver and remnant liver nomograms demonstrated strong predictive performance for PHLF with the optimism-corrected area under the curve of 0.78 and 0.81, respectively. Clinical relevance These nomograms can effectively stratify the risk of PHLF, providing a valuable tool for treatment decisions regarding hepatectomy for HCC.

Advanced Multiparametric MRI Strategies for Tumor Restaging After Neoadjuvant Therapy in Locally Advanced Gastric Cancer

BACKGROUND

This study tested the diagnostic accuracy of multiparametric magnetic resonance imaging (mpMRI) in restaging locally advanced gastric cancer after neoadjuvant therapy (NAT) using pathologic T stage (ypT) and pathologic N stage (ypN) as the reference standard.

METHODS

Between August 2022 and September 2023, the study enrolled a prospective cohort of 70 gastric cancer patients who underwent NAT and subsequent surgical resection. MRI procedures, including DLSB T2-weighted imaging (T2WI), ZOOMit diffusion-weighted imaging (DWI), and XD-VIBE dynamic contrast-enhanced imaging (DCE), were performed after NAT and before surgery. Four abdominal radiologists independently assigned radiologic T stage (yrT) and radiologic N stage (yrN) based on individual and combined sequences. Inter-reader agreement was quantified using Kendall's coefficient. Diagnostic accuracy was determined by comparing MRI assessments and pathologic outcomes, with pairwise comparisons analyzed via the McNemar test. Subgroup analysis evaluated the performance in identifying good responders to NAT.

RESULTS

Inter-reader agreement was almost perfect for T restaging and substantial for N restaging. Diagnostic accuracy for T restaging was 0.432 using DLSB-T2WI, 0.586 using ZOOMit DWI, 0.557 using XD-VIBE DCE, and 0.586 using mpMRI. The accuracy demonstrated by DWI, DCE and mpMRI was superior to that of T2WI (all P < 0.05). For N restaging, the accuracy of the mpMRI protocol was 0.443. Notably, mpMRI achieved an AUC of 0.879 (95% confidence interval 0.835-0.915) for differentiating ypT0-1 tumors.

CONCLUSIONS

Advanced mpMRI strategies can serve as a valuable tool for restaging gastric cancer after NAT. Accurately differentiating good responders to neoadjuvant therapy through mpMRI holds significant clinical implications for personalized treatment strategies and improved patient outcomes.

Long-Term Survival and Prognostic Factors of Stereotactic Body Radiotherapy Following Transarterial Chemoembolization for Hepatocellular Carcinoma

BACKGROUND/AIMS

This study presents a detailed analysis of long-term survival and critical factors influencing the outcomes of hepatocellular carcinoma patients treated with stereotactic body radiotherapy (SBRT) and transarterial chemoembolization (TACE). Our findings provide reassurance about the potential of the combination of TACE and SBRT as an effective treatment strategy for patients with large liver tumors due to HCC.

METHODS

A prospective study was conducted on 42 patients with intermediate-stage hepatocellular carcinoma (HCC) at 108 Military Central Hospital between December 2018 and June 2024. Following a single session of TACE, each patient underwent SBRT 1 month later. The SBRT dose ranged from 27.5 to 48 Gy, delivered in 3-5 fractions. The patient survival analysis was conducted using the Kaplan-Meier method while examining prognostic factors influencing survival, which involved log-rank tests and Cox proportional hazards regression analysis.

RESULTS

Among the 42 patients (83.3% male), 34 patients (81.0%) had tumors measuring ≥ 5 cm. The median follow-up period was 32.2 months (4.5-65.1 months). The median overall survival (OS) was 32.6 months, with the respective 1-, 3-, and 5-year OS rates reported as 73.8%, 24.5%, and 19.6%. Furthermore, the median progression-free survival (PFS) was 16.6 months, with corresponding 1- and 3-year PFS rates of 71.4% and 19.0%. Factors linked to improved OS and PFS included AFP levels and treatment response based on Modified RECIST criteria. Additionally, multivariate analysis identified patient age, EQD2, and BED10 as significant predictors of better survival outcomes.

CONCLUSIONS

Our study provides evidence supporting the effectiveness and safety of combining TACE and SBRT as a treatment strategy for patients with large liver tumors due to HCC, instilling confidence in the future of HCC treatment. Positive prognostic factors included patient age, EQD2, and BED10.

Quality of bowel preparation for colonoscopy in patients on glucagon-like peptide-1 receptor agonists

BACKGROUND AND AIMS

We aimed to assess the quality of bowel preparation in a matched cohort of patients actively using and not using glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in a large health system in the United States.

METHODS

We performed a retrospective review of adult patients undergoing colonoscopy in 22 endoscopy units across 18 sites in the United States.

RESULTS

Our cohort comprised 6235 patients (3344 case patients and 2891 control patients). Baseline variables causing suboptimal bowel preparation were setting of procedure (inpatient), sex (male), body mass index (higher), type 2 diabetes mellitus, inflammatory bowel disease, opioid medications, heart failure, and cirrhosis. Total Boston Bowel Preparation Scale was significantly higher in control patients even after controlling for the mentioned variables (P < .01). Case patients were significantly more likely to meet the definition of inadequate bowel preparation. There was no significant difference between different classes of GLP-1 RAs.

CONCLUSIONS

Patients using GLP-1 RAs are more likely to have inadequate bowel preparation during colonoscopy, even accounting for other comorbidities.

Long-term validation of intra-cystic biomarkers for pancreatic cysts

BACKGROUND

Pancreatic Cyst Lesions (PCLs) are frequently diagnosed in radiologic imaging tests and can be classified as benign, premalignant and malignant. Their correct stratification is essential and has significant implications for the patient. The objective of the study was to determine the clinical and analytical characteristics that can help in their differential diagnosis.

METHODS

This observational retrospective study included patients with PCLs diagnosed by endoscopic ultrasound from 2011 to 2023. Data collected included age, sex, personal history, treatments, toxic habits, family history of cancer, body mass index, and radiological and serological findings. The following intra-cyst levels were gathered: glucose, amylase, lipase, CEA and CA19.9.

RESULTS

271 patients with PCLs were included, 93 (35%) of them were benign, 55 (20%) were premalignant, and 123 (45%) malignant. Serous cystadenomas were the most common benign lesion in 71 (76%) patients. Within the premalignant group, intraductal papillary mucinous neoplasms (IPMNs) were the most common in 85% (47) patients. Cystic adenocarcinoma was the most prevalent malignant PCLs in 102 (83%) patients. Intra-cystic CEA value was the only parameter able to differentiate benign from malignant/premalignant lesions. Thirty (11%) patients underwent surgery with a final diagnosis of a malignant lesion in 13 (43%) patients, premalignant lesions in 5 (23%) (4 IPMNs and 1 mucinous cystadenoma) and benign cysts in 12 (40%). Five (38%) of the 13 malignant lesions were diagnosed at stages III/IV.

CONCLUSION

Intra-cyst CEA values can help us to classify premalignant PCNs. However, additional biomarkers and clinical parameters are required to better discriminate patients at the time of PCLs detection.

Comparison of conventional and novel rotational FNA needles using conventional microscopy and image analysis to quantitatively assess yield

BACKGROUND

There is increasing interest in designing new fine-needle aspiration (FNA) needles to maximize tissue acquisition. This study compares cytological preparations from a new rotating FNA needle (CytoCore) with conventional FNA (ConvFNA) using semiquantitative evaluation and quantitative image analysis (IA).

METHODS

FNA were performed on ex vivo tissue in quadruplicate for each needle type (ConvFNA and CytoCore), including different sizes (22 G and 25 G) and variable procedure time (5 and 20 s). The Nikon Elements (v5.41.02) was used to quantify the cellularity and size of the largest tissue fragment on cell blocks.

RESULTS

A total of 96 cytology specimens were evaluated were evaluated from benign and malignant specimens. For both ConvFNA and CytoCore, a longer procedure time (20 s) tended to produce greater cellularity and larger tissue fragments in the cell block specimens for both needles when analyzed with image analysis and was statistically significant for the CytoCore needle (p < .01). The ConvFNA tended to perform better with short procedure time. There was no statistically significant difference using different needle gauges.

CONCLUSION

This study shows that IA can help to quantitatively evaluate sample cellularity in the cell blocks from specimens acquired with different needles. A longer procedure time tended to produce more cellular samples and larger tissue fragments in the cell block for both ConvFNA and CytoCore needles and was statistically significant for CytoCore. Additional larger studies, including those with true clinical cases, should be considered to evaluate the different needle types further.

HLA DQA1*05 and Risk of Antitumor Necrosis Factor Treatment Failure and Anti-Drug Antibody Development in Children With Crohn's Disease

INTRODUCTION

Human leukocyte antigen (HLA) DQA1*05 has been associated with the development of anti-drug antibodies (ADA) to tumor necrosis factor antagonists (anti-TNFα) and treatment failure among adults with Crohn's disease (CD). However, findings from other studies have been inconsistent with limited pediatric data.

METHODS

We analyzed banked serum from patients with CD aged <21 years enrolled in clinical outcomes of Methotrexate Binary Therapy in practice, a multicenter, prospective randomized trial of anti-TNFα monotherapy vs combination with methotrexate. The primary outcome was a composite of factors indicative of treatment failure. The secondary outcome was ADA development.

RESULTS

A trend toward increased treatment failure among HLA DQA1*05-positive participants was not significant (hazard ratio 1.58, 95% confidence interval [CI] 0.95-2.62; P = 0.08). After stratification by HLA DQA1*05 and by methotrexate vs placebo, patients who were HLA DQA1*05 negative and assigned to methotrexate experienced less treatment failures than HLA DQA1*05-positive patients on placebo (hazard ratio 0.31, 95% CI 0.13-0.70; P = 0.005). A trend toward increased ADA development among HLA DQA1*05-positive participants was not significant (odds ratio 1.96, 95% CI 0.90-4.31, P = 0.09). After further stratification, HLA DQA1*05-negative participants assigned to methotrexate were less likely to develop ADA relative to HLA DQA1*05-positive patients on placebo (odds ratio 0.12, 95% CI 0.03-0.55; P = 0.008).

DISCUSSION

In a randomized trial of children with CD initiating anti-TNFα, 40% were HLA DQ-A1*05 positive, which was associated with a trend toward increased risk of both treatment failure and ADA. These risks were mitigated, but not eliminated, by adding oral methotrexate. HLA DQ-A1*05 is an important biomarker for prognosis and risk stratification.

Prevalence of "one and done" phenomenon in adenoma detection within a large community-based healthcare system

BACKGROUND AND AIMS

Adenoma detection rate (ADR) is a key quality metric in colonoscopy, reflecting the ability to detect adenomas. However, concerns remain regarding the robustness of ADR as a benchmark. In particular, the "one and done" phenomenon may exist in which physicians are less motivated to find additional adenomas after discovery of the first adenoma. To investigate this topic further, our goal was to understand the relationship between single and multiple adenoma detection.

METHODS

A retrospective cohort study was conducted by using data from 89,587 screening colonoscopies performed by 32 endoscopists within the Sutter Health-Palo Alto Medical Foundation between 2015 and 2020. ADR, single adenoma detection rate (ADR1), and multiple adenoma detection rate (ADR2+) were analyzed by using multivariate logistic regression and linear regression models. Endoscopists were then fit into 4 categories based on median ADR1 and ADR2+ (low ADR1, high ADR2+ ["all or none"], low ADR1, low ADR2+ ["none and done"], high ADR1, high ADR2+ ["all and done"], or high ADR1, low ADR2+ ["one and done"]).

RESULTS

The overall ADR was 45.4%. ADR, ADR1, and ADR2+ were significantly associated with similar factors, including older age, male sex, higher body mass index, smoking status, high-risk colonoscopies, Medicare insured, use of mucosal assist devices, longer withdrawal times, adequate preparation, and procedures performed by high-volume, female endoscopists with a longer duration in practice. The median ADR1 and ADR2+ were 23.95% and 21.29%, respectively. ADR1 and ADR2+ were positively correlated (Pearson correlation coefficient [r], .701; P < .001). Only 4 of 32 endoscopists fit our "one and done" category.

CONCLUSIONS

These findings suggest that ADR1 correlates with ADR2+. Despite concerns, the "one and done" phenomenon is not commonly seen in clinical practice. ADR remains a good surrogate marker for multiple adenoma detection.

Revisiting the causal impact of lipid traits on metabolic dysfunction-associated fatty liver disease: Insights from a multidimensional plasma lipid profile

AIMS

Recent advancements in plasma lipidomes genome-wide association studies data have enhanced our understanding of lipid categories, significantly improving risk assessments for metabolic dysfunction-associated fatty liver disease (MAFLD) beyond traditional lipid biomarkers.

MATERIALS AND METHODS

This study utilized Mendelian randomization (MR) to assess the causal relationships between 179 lipid species across 13 subclasses and MAFLD, primarily using the Wald ratio and IVW methods. Corrections were made using false discovery rate (FDR), supplemented by Bayesian colocalization analysis.

RESULTS

Elevated levels of genetically predicted phosphatidylcholine (16:0_16:1) [ORWald ratio = 2.638, 95% CI 1.557-4.469, P = 3.11 × 10-4], phosphatidylcholine (16:1_18:0) (ORWald ratio = 2.644, 95% CI 1.559-4.486, P = 3.11 × 10-4), triacylglycerol (46:2) (ORWald ratio = 2.515, 95% CI 1.524-4.153, P = 3.11 × 10-4), and triacylglycerol (48:2) (ORIVW = 1.863, 95% CI 1.300-2.669, P = 6.95 × 10-4) were significantly associated with increased MAFLD risk, with rs1260326 within the GCKR gene playing a crucial role. Colocalization analysis indicated that in significant evidences, the posterior probability for hypothesis 4 was over 80%, identifying rs780093 as a shared causal variant. Additionally, 16 suggestive evidences were identified.

CONCLUSION

The study confirmed the significant role of specific lipid molecules in influencing MAFLD risk, providing new scientific bases and potential therapeutic targets for future treatment strategies.