Clinical Implementation of Artificial Intelligence in Gastroenterology: Current Landscape, Regulatory Challenges, and Ethical Issues

Artificial intelligence (AI) is set to rapidly transform gastroenterology, particularly in the field of endoscopy, where algorithms have demonstrated efficacy in addressing human operator variability. However, implementing AI in clinical practice presents significant challenges. The regulatory landscape for AI as a medical device continues to evolve with areas of uncertainty. More robust studies generating real-world evidence are required to ultimately demonstrate impacts on patient outcomes. Cost-effectiveness data and reimbursement models will be pivotal for widespread adoption. Novel challenges are posed by emerging technologies, such as generative AI. Ethical and medicolegal concerns exist relating to data governance, patient harm, liability, and bias. This review provides an overview for clinical implementation of AI in gastroenterology and offers potential solutions to current barriers.

Multiregion Genomic Analysis of Human Pancreatic Mucinous Cystic Neoplasms

Mucinous cystic neoplasms (MCNs) are precursors to invasive pancreatic cancer. Conflicting clinical management recommendations call for better molecular characterization to improve our understanding of their tumorigenesis and risk assessment. We sampled epithelial tissue from a total of 18 surgically resected MCNs and performed dedicated multiregion analysis of somatic genetic alterations by targeted next-generation sequencing of 25 driver genes. In addition, we performed whole-exome sequencing and immunohistochemistry on selected samples to supplement our analyses. In total, 128 samples of epithelial MCN tissue were sequenced and analyzed, including samples from 13 small MCNs with low-grade (LG) dysplasia, 1 small MCN with high-grade (HG) dysplasia (HGD), and 4 large MCNs with HGD. Eight of 13 (61.5%) comprehensively sampled small LG MCNs lacked somatic driver gene mutations in all tissue blocks. These MCNs were lined by predominantly flat epithelium. In contrast, the majority of MCNs with driver gene mutations were predominantly lined by mucin-rich epithelium. No heterogeneity in KRAS mutations was seen across the sampled regions. Multiregion genetic analysis of 4 large MCNs with HGD provide insights into neoplastic progression, with shared somatic alterations suggesting that HGD arises from LG mucin-rich epithelium. These findings were supported by complementary whole-exome sequencing studies in 26 MCN epithelium samples. The neoplastic epithelium in the majority of small MCNs does not harbor somatic mutations in pancreatic driver genes. The genetic findings from multiregion analysis on MCNs contrast previous investigations in other mucin-producing pancreatic cysts, indicating distinct mechanisms in early tumorigenesis. This calls for a more nuanced risk assessment in MCNs, requiring improved preoperative assessment tools.

Modified cornstarch as an effective treatment for insulinoma-induced hypoglycemia: a case report

A 90-year-old male was admitted to the hospital due to recurrent symptomatic hypoglycemia. After ruling out the most common outpatient causes of hypoglycemia, endogenous hyperinsulinism was confirmed. An abdominal computed tomography (CT) scan revealed a 15 mm solid nodular lesion in the pancreatic tail. The (68)Ga-DOTA-TOC PET-CT findings led to the diagnosis of insulinoma. A multidisciplinary committee considered the patient unfit for surgery. The treatment was started with a low dose of diazoxide; however, side effects appeared as the dose was gradually increased. Consequently, a dietary approach was prioritized, incorporating modified cornstarch (Glycosade®) in fractionated doses administered under the guidance of continuous glucose monitoring. This strategy allowed for a reduction in the diazoxide dosage and effectively prevented further hypoglycemic episodes without additional side effects. Since the initial medical treatment was successful, the patient and his family preferred to avoid other possible minimally invasive treatments unless pharmacological and dietary approaches failed.

The impact of glucagon-like peptide-1 receptor agonists on the quality indicators of colonoscopy - a systematic review and meta-analysis

BACKGROUND

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are a newer class of glucose-lowering drugs with established cardiovascular benefit. However, their impact on bowel preparation quality remains controversial.

AIMS

This article aimed to assess the association between GLP-1 RA use and colonoscopy quality indicators.

METHODS

Electronic searches of PubMed and Embase were conducted up to January 2025. Clinical trials comparing colonoscopy quality indicators between GLP-1 RA users and controls were included. Non-English literature, meeting abstracts, and unpublished data were excluded. The primary outcome was the rate of inadequate bowel preparation; secondary outcomes included BBPS scores and adenoma/polyp detection rate (ADR/PDR).

RESULTS

Six trials were included, involving 8778 GLP-1 RA users and 8290 controls. GLP-1 RA users had a higher rate of inadequate bowel preparation (risk difference = 0.06, 95 % CI 0.05-0.08, p < 0.001, I² = 39 %). Total BBPS scores were lower among GLP-1 RA users (mean difference = -0.31, 95 % CI -0.39--0.23, p < 0.001, I² = 0 %). Two studies reported increased ADR/PDR in GLP-1 RA users; one showed a neutral result.

CONCLUSION

GLP-1 RA is associated with inadequate bowel preparation. Further research is needed to establish the optimal GLP-1 RA washout period before colonoscopy.

Construction and validation of machine learning-based predictive model for colorectal polyp recurrence one year after endoscopic mucosal resection

BACKGROUND

Colorectal polyps are precancerous diseases of colorectal cancer. Early detection and resection of colorectal polyps can effectively reduce the mortality of colorectal cancer. Endoscopic mucosal resection (EMR) is a common polypectomy procedure in clinical practice, but it has a high postoperative recurrence rate. Currently, there is no predictive model for the recurrence of colorectal polyps after EMR.

AIM

To construct and validate a machine learning (ML) model for predicting the risk of colorectal polyp recurrence one year after EMR.

METHODS

This study retrospectively collected data from 1694 patients at three medical centers in Xuzhou. Additionally, a total of 166 patients were collected to form a prospective validation set. Feature variable screening was conducted using univariate and multivariate logistic regression analyses, and five ML algorithms were used to construct the predictive models. The optimal models were evaluated based on different performance metrics. Decision curve analysis (DCA) and SHapley Additive exPlanation (SHAP) analysis were performed to assess clinical applicability and predictor importance.

RESULTS

Multivariate logistic regression analysis identified 8 independent risk factors for colorectal polyp recurrence one year after EMR (P < 0.05). Among the models, eXtreme Gradient Boosting (XGBoost) demonstrated the highest area under the curve (AUC) in the training set, internal validation set, and prospective validation set, with AUCs of 0.909 (95%CI: 0.89-0.92), 0.921 (95%CI: 0.90-0.94), and 0.963 (95%CI: 0.94-0.99), respectively. DCA indicated favorable clinical utility for the XGBoost model. SHAP analysis identified smoking history, family history, and age as the top three most important predictors in the model.

CONCLUSION

The XGBoost model has the best predictive performance and can assist clinicians in providing individualized colonoscopy follow-up recommendations.

EUS-guided fine-needle biopsy sampling of solid pancreatic masses with and without rapid onsite evaluation for commercial next-generation genomic profiling

BACKGROUND AND AIMS

Although EUS-guided fine-needle biopsy sampling (EUS-FNB) of solid pancreatic lesions with or without the use of rapid onsite evaluation (ROSE) provides a high diagnostic yield, the utility of ROSE for commercial genomic analysis is unclear.

METHODS

A multicenter retrospective review was conducted of consecutive patients where genomic analysis was requested from EUS-FNB of solid pancreatic lesions, performed with 22-gauge fine-needle biopsy (FNB) needles. Data were collected at 2 academic centers, one that routinely uses ROSE to assess adequacy for all EUS-FNB cases (University of California San Francisco, n = 44) and one that does not use ROSE (Washington University, n = 186).

RESULTS

The cohort consisted of 230 patients (mean age, 67.3 ± 9.8 years; 52.6% women). There were no significant differences between patient and tumor characteristics or locations in the 2 groups. Adverse events were uncommon and similar between the groups (1.6% vs 0%). Adequacy for genomic evaluation was high and similar between those cases without and with ROSE (159/186 [85.5%] vs 39/44 [88.6%], P = .8). Genomic analysis resulted in potentially actionable mutations in a similar number of cases without and with ROSE (18.3% vs 15.9%, P = .82). However, compared with FNB sampling without ROSE, FNB sampling with ROSE required more than double the procedure time (mean, 21.1 ± 10 minutes vs 49.7 ± 20.6 minutes; P < .001) and a significantly higher number of median needle passes (3 [IQR, 2-3] vs 4 [IQR, 3-4], P < .001).

CONCLUSIONS

Although EUS-FNB with ROSE did not have a significantly different adequacy for commercial genomic analysis compared with EUS-FNB without ROSE, it required significantly more procedure time and needle passes.

Latest Advances in Pancreatobiliary Endoscopy

The field of biliopancreatic endoscopy has witnessed transformative advancements, driven by technological innovations, novel techniques, and an evolving understanding of disease processes [...].

Complications of Endoscopic Retrograde Cholangiopancreatography

Up to 1 in 6 patients will experience an unplanned hospitalization after endoscopic retrograde cholangiopancreatography (ERCP), largely for the evaluation and management of adverse events. Therefore, a commitment to the prevention, early recognition, and effective rescue of complications related to ERCP is critical toward improving outcomes. ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur. The prevention of post-ERCP pancreatitis has been the area of greatest interest and progress in the last decade, but the application of evidence-based prophylactic measures remains inconsistent. Innovations in stent, hemostasis, and perforation closure technology now allow effective and efficient endoscopic management of several important nonpancreatitis complications. Overall, our ability to prevent and treat ERCP-related adverse events has improved substantially, amplifying the importance of a high level of suspicion for and a thorough understanding of these events.

Spatial analysis of IPMNs defines a paradoxical KRT17-positive, low-grade epithelial population harboring malignant features

Background & Aims

Intraductal papillary mucinous neoplasms (IPMNs) are pancreatic cysts that represent one of the few radiologically identifiable precursors to pancreatic ductal adenocarcinoma (PDAC).Though the IPMN-bearing patient population represents a unique opportunity for early detection and interception, current guidelines provide insufficient accuracy in determining which patients should undergo resection versus surveillance, resulting in a sizable fraction of resected IPMNs only harboring low-grade dysplasia, suggesting that there may be overtreatment of this clinical entity.

Methods

To investigate the transcriptional changes that occur during IPMN progression, we performed spatial transcriptomics using the Nanostring GeoMx on patient samples containing the entire spectrum of IPMN disease including low-grade dysplasia, high-grade dysplasia, and IPMN-derived carcinoma. Single cell RNA sequencing was performed on side branch and main duct IPMN biospecimens.

Results

We identified a subpopulation of histologically low-grade IPMN epithelial cells that express malignant transcriptional features including KRT17 , S100A10 and CEACAM5 , markers that are enriched in PDAC. We validated and refined this high-risk gene signature by integrating our ST analysis with an external ST dataset containing a larger number of IPMN samples including non-tumor bearing IPMN (i.e. low-grade IPMN in isolation). We confirmed the presence of the KRT17+ population using immunofluorescence on a large cohort of patient tissues, revealing a widespread but patchy distribution of KRT17+ cells in histologically low-grade IPMN.

Conclusions

Our study demonstrates that KRT17 marks a distinct transcriptional signature in a subpopulation of epithelial cells within histologically low-grade IPMN. This population of cells likely represents a transitional state of histologically low-grade epithelial cells undergoing progression to a higher grade of dysplasia and thus may represent a higher risk of progression to carcinoma.

Graphical abstract

Impact of Antihypertensive and Lipid-Lowering Agents on Hepatocellular Carcinoma Risk in Patients with Fatty Liver Disease and Diabetes

BACKGROUND/AIM

This study aimed to evaluate the effects of antihypertensives, lipid-lowering agents, and antiplatelet medications on hepatocellular carcinoma (HCC) risk in patients with fatty liver disease (FLD) and type 2 diabetes (T2D).

METHOD

Using data from Korea Health Insurance Review and Assessment Service, 212,443 FLD-T2D patients were analyzed through Cox regression, propensity score matching (PSM), and Kaplan-Meier analysis. The analysis considered medication use and its relation to HCC development. Cohort admission day was set as the date of the first oral hypoglycemic prescription.

RESULTS

The multivariate Cox regression analysis revealed that old age, male sex, chronic viral hepatitis, alcoholic liver disease, liver cirrhosis, using a combination of insulin and oral hypoglycemic agents for antidiabetic treatment, and calcium channel blocker (CCB) use were significantly correlated with higher HCC development risk, whereas dyslipidemia and statin, ezetimibe, and fibrate use was correlated with lower HCC risk, in the study cohort of 212,443 patients. Patients who used statins (hazard ratio [HR] = 0.58, 95% confidence interval [CI] = 0.42-0.80, P = 0.001) and fibrates (HR = 0.46, 95% CI = 0.22-0.93, P = 0.031) showed a significantly lower risk of HCC development even after PSM. In contrast, CCB use was linked to an elevated HCC risk (HR = 1.35, 95% CI = 1.05-1.72, P = 0.019), highlighting the differential impact of various medications on HCC incidence.

CONCLUSION

The use of specific medications, such as statins and fibrates, may offer protective effects against HCC in patients with FLD-T2D, whereas that of CCB may increase the risk. This underscores the importance of tailored medication strategies for the management of chronic conditions.

Preoperative prediction of pancreatic neuroendocrine tumors grade based on computed tomography, magnetic resonance imaging and endoscopic ultrasonography

PURPOSE

To establish a preoperative prediction model for pathological grade of PanNETs based on computed tomography (CT), magnetic resonance imaging (MRI) and endoscopic ultrasonography (EUS).

METHODS

Clinical data of 58 patients with pathologically confirmed PanNETs were included in this retrospectively study and they were divided into grade 1 and grade 2/3. CT, MRI and EUS images were collected within one week before surgery. A clinical predictive model based on the independent clinical risk factors and significant radiological features was established. The area under receiver operating characteristic curve (AUC) was performed to assess the model.

RESULTS

Gender, pancreatic duct dilatation (PDD) and portal enhancement ratio (PER) were the independent predictors for PanNETs grading (P < 0.05). PanNETs grade 1 and grade 2/3 had statistical difference in elastography score (P = 0.001). The combination of gender, PDD and PER had better predictive efficiency than each of these three predictors alone, with a high AUC of 0.925. The elastography score also achieved an AUC of 0.838.

CONCLUSION

We proposed a comprehensive model based on preoperative CT, MRI and EUS to predict grade 1 and grade 2/3 of PanNETs and better informs clinicians on individualized diagnosis and treatment of patients with PanNETs.

Hepatocellular Carcinoma After HCV Eradication with Direct-Acting Antivirals: A Reappraisal Based on New Parameters to Assess the Persistence of Risk

Approximately 95% of patients with chronic hepatitis C achieve viral eradication through direct-acting antiviral (DAA) treatment. Ensuing clinical benefits include halting liver fibrosis, thereby reducing the need for liver transplantation, and decreasing both liver-related and overall mortality. It is well established that, although ameliorated, the risk of developing hepatocellular carcinoma (HCC) persists, particularly among patients with pre-treatment advanced fibrosis/cirrhosis. Current guidelines recommend indefinite HCC surveillance in these patients. However, a recent Markov model evaluation shows that HCC surveillance is cost-effective only for patients with cirrhosis but not so for those with F3 fibrosis, a finding which points out the need to better define the risk of HCC in hepatitis C patients after cure and further characterize pre- and post-treatment factors that might affect the incidence of HCC in this setting. We reviewed the literature analyzing this aspect. Here we summarize the main findings: male gender and older age are independent predictors of increased risk of post-cure HCC development. Moreover, non-invasive tests for hepatic fibrosis, namely FIB4, APRI, and liver stiffness, measured before and after treatment and their post-therapy change, contribute to better stratifying the risk of HCC occurrence. Furthermore, low serum albumin, as well as an AFP above 7 ng/mL prior to and after DAA therapy, also constitute independent predictors of HCC development. Considering these findings, we propose to classify patients with HCV viral eradication and advanced fibrosis/cirrhosis into groups of low, medium, or high risk of HCC and to adopt adequate surveillance strategies for each group, including protocols for abbreviated magnetic resonance imaging (MRI) for those at the highest risk.

Deep Learning-Based Semantic Segmentation for Objective Colonoscopy Quality Assessment

Background: This study aims to objectively evaluate the overall quality of colonoscopies using a specially trained deep learning-based semantic segmentation neural network. This represents a modern and valuable approach for the analysis of colonoscopy frames. Methods: We collected thousands of colonoscopy frames extracted from a set of video colonoscopy files. A color-based image processing method was used to extract color features from specific regions of each colonoscopy frame, namely, the intestinal mucosa, residues, artifacts, and lumen. With these features, we automatically annotated all the colonoscopy frames and then selected the best of them to train a semantic segmentation network. This trained network was used to classify the four region types in a different set of test colonoscopy frames and extract pixel statistics that are relevant to quality evaluation. The test colonoscopies were also evaluated by colonoscopy experts using the Boston scale. Results: The deep learning semantic segmentation method obtained good results, in terms of classifying the four key regions in colonoscopy frames, and produced pixel statistics that are efficient in terms of objective quality assessment. The Spearman correlation results were as follows: BBPS vs. pixel scores: 0.69; BBPS vs. mucosa pixel percentage: 0.63; BBPS vs. residue pixel percentage: -0.47; BBPS vs. Artifact Pixel Percentage: -0.65. The agreement analysis using Cohen's Kappa yielded a value of 0.28. The colonoscopy evaluation based on the extracted pixel statistics showed a fair level of compatibility with the experts' evaluations. Conclusions: Our proposed deep learning semantic segmentation approach is shown to be a promising tool for evaluating the overall quality of colonoscopies and goes beyond the Boston Bowel Preparation Scale in terms of assessing colonoscopy quality. In particular, while the Boston scale focuses solely on the amount of residual content, our method can identify and quantify the percentage of colonic mucosa, residues, and artifacts, providing a more comprehensive and objective evaluation.

A cost-effective measure to prevent hemorrhage in ultrasound-guided percutaneous liver biopsy

BACKGROUND

Liver biopsy is a procedure whereby a biopsy needle is used to extract tissue from the liver parenchyma or focal lesions of the liver for pathological or microbiological examination. Percutaneous liver biopsy(PC-LB) is the most commonly employed and least expensive modality. However, it is associated with a significant risk of bleeding complications, which may potentially result in patient mortality. The objective of this study was to investigate the efficacy of Absorbable Gelatin Sponge sheet filler agent (AGS-SFA) in preventing bleeding complications during liver tissue biopsy and to validate a cost-effective surgical technique.

METHODS

In this study, patients who underwent ultrasound-guided percutaneous liver tissue biopsy at our hospital were selected and randomly assigned to either an observation or control group. The observation group employed the use of AGS-SFA to fill the biopsy needle channel. Immediately following the biopsy procedure, the biopsy needle path was examined using Doppler ultrasound. The incidence of bleeding complications following biopsy and the associated factors influencing bleeding were analysed in the two groups.

RESULTS

The observation and control groups were successfully biopsied, with a 100% success rate for both. The incidence of bleeding complications was significantly lower in the observation group than in the control group. Four factors, including fatty liver, prothrombin time, albumin and INR, were found to have a significant effect on biopsy bleeding in the control group.

CONCLUSION

The use of coaxial needles to inject AGS-SFA is an effective and economical procedure that significantly improves the safety of biopsy without increasing the burden of patient care.

Efficacy and safety of biologic therapy for Crohn's disease: An overview of meta-analyses and systematic reviews

OBJECTIVE

To present an overview to summarize the efficacy and safety of biologics for the treatment of Crohn's disease (CD).

METHODS

We gathered systematic reviews or meta-analyses on the efficacy and safety of biologic therapy for CD from the beginning to September 30, 2023, by searching the databases of the Chinese National Knowledge Infrastructure (CNKI), WanFang Data, China Science and Technology Journal Database, Web of Science, the Cochrane Library, PubMed, and Embase. Analysing reviews and extracting data, two researchers worked independently. Any discrepancies in the two researchers' assessments of the review process were reevaluated, and the argument was settled by consulting to other researchers. The following details was taken out of the data: author, publication year, study type, number of included studies, country of study, sample size, risk bias tools, biologic therapy, and primary outcomes. Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) and the AMSTAR-2, a critical appraisal tool for systematic reviews (2nd edition), were then utilized to assess the methodological quality and reporting quality of the evidence.

RESULTS

There were 19 reviews in all. One systematic review, 5 meta-analyses, and 13 systematic reviews and meta-analyses were among the reviews that were included. Nine studies met the high quality, 5 met the moderate quality, 3 met the poor quality, and 2 met the critically low quality requirements of the AMSTAR-2 criteria.

CONCLUSIONS

The analysis of the evidence finds biologic agents for CD are effective and safe. Overall, there was moderate to high quality biologic evidence for CD, but future head-to-head controlled studies are required to better inform the relative positioning of these drugs for the management of CD.

Liver Cirrhosis: ancient disease, new challenge

Liver cirrhosis is a common cause of morbidity and mortality worldwide. Excessive alcohol consumption and metabolic associated steatotic liver disease are the most common etiological factors of cirrhosis in our region. Cirrhosis occurs in two well-differentiated phases, compensated and decompensated, depending on the absence or presence of complications, respectively. Current therapeutic strategies are aimed at controlling these complications (such as ascites, hepatic encephalopathy, bacterial infections, or digestive hemorrhage, among others) or performing a liver transplant if there are no contraindications. However, it is important to eliminate the etiological factor responsible for the disease, as this can lead to the disappearance of complications, a state known as recompensation. This article proposes an updated review of the epidemiology of cirrhosis and its main causes, and offers an overview of the clinical features and treatment of the disease's complications, in addition to outlining future lines of research in this field.

A survey of emergency medicine physicians' knowledge, attitude, and practice towards esophagogastric variceal bleeding

BACKGROUND

Esophageal-gastric variceal bleeding (EVB) is one of the leading causes of mortality in patients with cirrhotic portal hypertension. Rapid, accurate, and effective emergency care is crucial for successful patient outcomes.

AIMS

This study aims to evaluate the knowledge, attitudes, and practices of Chinese emergency physicians regarding EVB, with the goal of improving the diagnosis and treatment of gastrointestinal bleeding in emergency settings.

METHODS

A self-designed questionnaire based on clinical guidelines was developed to assess EVB knowledge, attitudes, and practices of Chinese emergency physicians in treating EVB. An online survey was conducted among emergency physicians nationwide. Data were analyzed using descriptive statistics and correlation analysis.

RESULTS

The knowledge score for EVB was 11.2 ± 3.5 (total score was 22), indicating a relatively low level of understanding. Statistically significant differences in knowledge scores were observed across hospital grades, educational backgrounds, years of experience, professional titles, and participation in relevant training programs (P < 0.05). The mean attitude score for EVB was above 4 (total score was 5), reflecting a generally positive attitude among physicians. In terms of practices, the score for treatment behavior of EVB was 2.7 ± 1.2, and behavior was positively correlated with knowledge and attitude (P < 0.05).

CONCLUSION

Chinese emergency physicians demonstrate a low level of knowledge about EVB treatment, although their attitudes remain positive. Their clinical practices in EVB management are also insufficient. Enhancing education on EVB and standardizing treatment protocols are necessary to improve patient outcomes.

Development and validation of a dynamic prognostic nomogram for conditional survival in hepatocellular carcinoma: an analysis from the Korea Liver Cancer Registry

Compared to overall survival, conditional survival is a more relevant measure of prognosis in surviving patients over time. This study developed and validated a nomogram-based dynamic prognostic model to predict the conditional survival estimates of patients with hepatocellular carcinoma (HCC) through an analysis of a nationwide cancer registry. This retrospective cohort study included 2492 patients with HCC registered in the Korea Liver Cancer Registry. Patients underwent hepatic resection (HR) from 2008 to 2017, were followed up until December 2019, and were divided into development and validation cohorts. Univariate and multivariate Cox regression analyses were conducted to determine the risk factors for conditional survival of patients who underwent HR. The patients were scored based on the Cox regression coefficients; the nomogram was predicted by calculating the survival probability with Cox model. Our dynamic prognostic model nomogram for predicting conditional overall survival demonstrated Harrell's C-index of 0.622 and 0.674 in the development and validation sets; for conditional disease-specific survival, it was 0.623 and 0.686 in the development and validation sets. The prediction power of the model is applicable in clinical practice. Factors incorporated in our nomogram included age, albumin, the ADV score, lymph node metastasis, and T stage in American Joint Commission on Cancer staging system. We developed and validated a nomogram to predict conditional survival estimates for overall survival and disease-specific survival. The proposed nomogram incorporating the ADV score presents a more accurate and useful prognostic prediction for patients with HCC who received HR.

The Endoscopic Management of Anastomotic Strictures After Esophagogastric Surgery: A Comprehensive Review of Emerging Approaches Beyond Endoscopic Dilation

Anastomotic strictures are a common complication following esophagogastric surgery, with prevalence varying depending on the type of surgery and anatomical site. These strictures can lead to debilitating symptoms such as dysphagia, pain, and malabsorption, significantly impacting patients' quality of life. Endoscopic treatment of anastomotic strictures has established a role as the first-line strategy in this setting instead of revision surgery, offering benefits in terms of lower morbidity. Various endoscopic methods are available for anastomotic stricture management, including balloon dilation, stent placement, the new lumen-apposing metal stent, and endoscopic incision techniques. However, there is currently no strong evidence and established guidelines for the optimal treatment strategy. Available data suggest that endoscopic treatments, when performed in tertiary referral centers, can provide favorable outcomes in terms of symptom relief and reduced need for rescue surgical intervention. Nonetheless, challenges remain regarding the management of recurrent strictures and procedural complications, underscoring the need for a personalized, multidisciplinary approach to optimize clinical outcomes. This review aims to provide an updated overview of endoscopic techniques and available evidence with a focus on the most recent technologies, supporting clinicians in effectively managing anastomotic strictures in complex clinical settings.

Low-residue diet with oral nutritional supplements prior to colonoscopy improves the quality of bowel preparation: an endoscopist-blinded, randomized controlled trial

BACKGROUND

Poor bowel preparation has been a great problem of endoscopists for a long time. Low-residue diet (LRD) is often recommended on the day before colonoscopy. However, the quality of bowel preparation with LRD alone is suboptimal. The aim of our study was to examine whether patients who consumed LRD with oral nutritional supplements (ONSs) had higher quality of bowel preparation than patients who consumed LRD alone before colonoscopy.

METHODS

An endoscopist-blinded, randomized controlled trial was conducted in inpatients who scheduled for colonoscopy with sedation. Patients were randomized to the non-ONS group and the ONS group. The primary outcomes were the rates of adequate bowel preparation measured by the Boston Bowel Preparation Scale (BBPS), the Ottawa Bowel Preparation Scale (OBPS) and the Colon Endoscopic Bubble Scale (CEBuS). The secondary outcomes were the adenoma detection rate (ADR), polyp detection rate (PDR), intubation time, withdrawal time and rates of adverse events.

RESULTS

In both groups, 100 patients were analyzed. The rates of adequate bowel preparation measured by the BBPS and OBPS and PDR were significantly higher in the ONS group than in the non-ONS group (all P < 0.05). However, no significant differences were observed in the CEBuS scores, ADR, intubation time and rates of adverse events between the two groups (all P > 0.05). The withdrawal time was longer in the non-ONS group than the in the ONS group (P < 0.05).

CONCLUSIONS

LRD with ONSs helps increase the quality of bowel preparation. To help with colorectal cancer (CRC) screening, further studies are warrant.

TRIAL REGISTRATION

[Chinese Clinical Trial Registry], [ChiCTR2400091660], [31/10/2024], [Retrospectively registered].

Endoscopic ultrasound gastroenterostomy vs duodenal stenting for malignant gastric outlet obstruction: Cost-effectiveness study

Background and study aims

Enteral stenting has been traditionally employed for managing malignant gastric outlet obstruction (GOO). However, concerns regarding high reintervention rates have brought into question its cost-effectiveness. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with a lumen-apposing metal stent (LAMS) provides an alternative to luminal stenting. The goal of this study was to assess the cost-effectiveness of EUS-GE relative to duodenal stenting.

Patients and methods

A decision analysis was performed to analyze costs and survival in patients with unresectable or metastatic GOO. The model was designed with two treatment arms: self-expanding metal stent (SEMS) placement and EUS-GE with LAMS. Costs were derived from Medicare reimbursement rates (US$) while effectiveness was measured by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). Probabilistic sensitivity analyses were performed.

Results

Endoscopic stenting resulted in an average cost of $22,748 and 0.31 QALYs whereas EUS-GE cost $32,254 and yielded 0.53 QALYs, which yielded a difference of $9,507 in cost and 0.23 in QALY. EUS-GE was found to be a cost-effective strategy over duodenal stenting (ICER, $41994/QALY) at a willingness-to-pay of $100,000/QALY. In 10,000 Monte-Carlo simulations, EUS-GE was favored 62% of the time. Using a tornado diagram, the model was most sensitive to the probability of mortality in patients with duodenal stents compared with EUS-GE.

Conclusions

In patients with malignant GOO, EUS-GE is a cost-effective palliative intervention compared with duodenal stenting.

Artificial Intelligence-Driven Personalized Medicine: Transforming Clinical Practice in Inflammatory Bowel Disease

Inflammatory bowel disease is marked by significant clinical heterogeneity, posing challenges for accurate diagnosis and personalized treatment strategies. Conventional approaches, such as endoscopy and histology, often fail to adequately and accurately predict medium- and long-term outcomes, leading to suboptimal patient management. Artificial intelligence is emerging as a transformative force enabling standardized, accurate, and timely disease assessment and outcome prediction, including therapeutic response. Artificial intelligence-driven intestinal barrier healing assessment provides novel insights into deep healing, facilitating the discovery of novel therapeutic targets. In addition, the automated integration of multi-omics data can enhance patient profiling and personalized management strategies. The future of inflammatory bowel disease care lies in the artificial intelligence-enabled "endo-histo-omics" integrative real-time approach, harmoniously fusing endoscopic, histologic, and molecular data. Despite challenges in its adoption, this paradigm shift has the potential to refine risk stratification, improve therapeutic precision, and enable personalized interventions, ultimately advancing the implementation of precision medicine in routine clinical practice.

Efficacy of cisplatin-gemcitabine-durvalumab in patients with advanced biliary tract cancer experiencing early vs late disease relapse after surgery: a large real-life worldwide population

BACKGROUND

In the TOPAZ-1, patients with biliary tract cancers (BTC) and recurrence within 6 months after surgery were excluded, even if this event is frequently observed in clinical practice. Our study aimed to assess if the efficacy of cisplatin-gemcitabine-durvalumab (CGD) in this population is comparable to that reported in the phase 3 trial.

METHODS

The study cohort included patients with BTC who underwent surgery on the primary tumor, experienced disease recurrence occurring ≤6 months or >6 months after surgery or after the end of adjuvant therapy and started CGD. The primary objectives were overall survival (OS) and progression free survival (PFS).

RESULTS

A total of 178 patients were enrolled. No significant differences were observed between early and late relapse groups in OS (23.4 months vs not reached; HR 1.26; 95% CI, 0.67-2.37; P = .45) and PFS [7.0 months vs 9.8 months; HR 1.3(95% CI, 0.9-2.1) P = .13]. Overall response rate and disease control rate (P = .33 and P = .62) were comparable between the 2 groups, as the overall safety profile. In addition, we compared survival outcomes between the selected population and a historical cohort of patients with BTC treated with cisplatin-gemcitabine (CG) and found that despite the absence of statistical significance, CGD showed an outcome trend compared with CG regardless of the time of recurrence after surgery or adjuvant chemotherapy [(CG ≤ 6 vs CGD ≤ 6 months: HR 0.59, 95%CI, 0.35-1.01, P = .05; HR 0.70; 95%CI, 0.46-1.06, P = .09, OS and PFS, respectively) and (CG > 6 vs. CGD > 6 months: HR 0.50; 95%CI, 0.29-0.88, P = 0.0165; HR 0.54; 95%CI, 0.35-0.84, P = .0068, OS and PFS, respectively)].

CONCLUSION

Our analysis suggests that CGD retains its efficacy independently of the timing of relapse after surgery or completion of adjuvant treatment in patients with advanced BTC.

Role of Spleen Stiffness Measurements with 2D Shear-Wave Elastography for Esophageal Varices in Patients with Compensated Advanced Chronic Liver Disease

Background/Objectives: Esophageal varices (EVs) represent an important portal hypertension complication in patients with compensated advanced chronic liver disease (cACLD). Although upper gastrointestinal endoscopy is currently the gold standard for EV diagnosis, recent guidelines recommend non-invasive approaches to assess EV risk in cACLD patients to reduce unnecessary endoscopies. Our study aims to evaluate spleen stiffness measurement (SSM) using 2D shear-wave elastography (2D-SWE) as a non-invasive predictor of EV presence and severity in patients with cACLD. Methods: We included 73 cACLD patients referred to our liver clinic over one year. SSM and liver stiffness measurement (LSM) were performed using 2D-SWE, with specific cut-off values applied to rule in or rule out clinically significant portal hypertension (CSPH) according to Baveno VII consensus criteria. Upper gastrointestinal endoscopy was performed in all patients to confirm EV presence and grade. Results: Among all patients, 49.3% had no EV, while 50.7% presented with different EV grades (15.1% grade I, 13.7% grade II, 9.6% grade III, and 12.3% grade IV). A strong correlation was observed between elevated SSM values and EV presence, with SSM values > 32.8 kPa highly suggestive of EV (AUROC = 0.95, 95% CI: 0.909-0.995, p < 0.001). SSM values exceeding 40.4 kPa were associated with more advanced EV grades. Combining LSM and SSM improved diagnostic accuracy, effectively stratifying EV risk without invasive procedures. Conclusions: SSM via 2D-SWE is a promising, non-invasive tool for EV prediction in cACLD, aligning with Baveno VII recommendations to minimize unnecessary endoscopies. Further validation is required to refine diagnostic thresholds and expand applicability across different chronic liver disease etiologies.

Liver stiffness measurement trajectory analysis for prognosis in patients with chronic hepatitis B and compensated advanced chronic liver disease

INTRODUCTION AND OBJECTIVES

Liver stiffness measurements (LSMs) offer a noninvasive method for monitoring liver disease development. This study evaluated the prognostic value of different LSM trajectories in chronic hepatitis B (CHB) and compensated advanced chronic liver disease (cACLD) patients.

MATERIALS AND METHODS

We retrospectively analyzed 1272 CHB and cACLD patients with at least two LSMs, applied group-based trajectory modeling (GBTM) to identify distinct LSM trajectories, and used a Cox model to analyze their associations with liver-related events (LREs) and mortality risk.

RESULTS

Patients were categorized into five groups with distinct LSM trajectories: 67 (8.5 %), 13 (11 %), 36 (23.5 %), 34 (27.6 %) and 23 (25.0 %) developed LREs in Groups 1-5. The low stable trajectory (Group 3), the medium gradual decrease trajectory (Group 4) and high quickly decrease followed by increase trajectory (Group 5) had higher LREs risks than the low gradual decrease trajectory (Group 1) (adjusted HRs 2.26, 2.39, 2.67; 95 % CIs 1.50-3.40, 1.57-3.66, 1.61-4.43, respectively). Similar elevated risks were observed for hepatic decompensation, hepatocellular carcinoma (HCC), liver-related and all-cause mortality, except that there was no significant difference in the risk of HCC between Groups 4 and 1 (aHR 0.66, 0.36-1.23). When comparing Group 1 with the medium quickly decrease trajectory (Group 2), no significant differences were noted in the prognosis (P > 0.05). Notably, age over 40, high LSM, low PLT, and high total bilirubin were linked to high-risk trajectories (Groups 3-5).

CONCLUSIONS

Monitoring LSM trajectories improves prognostic prediction in CHB and cACLD compared with single measurements and may guide personalized treatment strategies.

Impact of parenchymal transection techniques on intraoperative blood loss during liver resection in a porcine model of elevated central venous pressure: A comparative study

INTRODUCTION AND OBJECTIVES

Liver resection is the standard treatment for resectable liver tumors and metastases. However, mortality and morbidity remain significant concerns, particularly for patients with chronically elevated central venous pressure (CVP), which increases perioperative complication risks. The optimal parenchymal transection technique for these patients remains unclear, necessitating further research.

MATERIALS AND METHODS

This study established an innovative porcine model for high-CVP liver resection. Animals were divided into two groups: a control group (CVP ≤ 5 mmHg, low-CVP) and an intervention group (CVP ≥ 10 mmHg, high-CVP). A left lateral liver resection was performed using three parenchymal transection techniques: clamp-crush (CC), harmonic scalpel (HS), and stapler (ST). The primary endpoint was intraoperative blood loss, while secondary endpoints included transection time and bile leakage.

RESULTS

No differences were found for blood loss or transection time among the low-CVP subgroups. In the high-CVP group, the HS and ST techniques were associated with significantly reduced blood loss and faster transection times than the CC technique. While transection times for the HS and ST were similar between the low- and high-CVP groups, they were significantly longer with the CC technique in the high-CVP group. The incidence of bile leakage was comparable across all three techniques.

CONCLUSIONS

This pilot study demonstrates superior outcomes for HS and ST techniques in high-CVP liver resections. Insights from this large animal model provide a basis for investigating optimal transection techniques for chronically elevated CVP, bridging preclinical research and clinical practice.

Small Bowel Motility Quantified by Cine MRI to Predict Longer-Term Response in Patients with Crohn's Disease Commencing Biological Therapy: The Motility Study

BACKGROUND

Small bowel Crohn's disease (SBCD) is increasingly treated with biological therapies. Predicting response or remission (RoR) for individual patients is difficult and complicates treatment strategy. We aimed to determine if motility magnetic resonance imaging (mMRI) is superior to CRP and fecal calprotectin (FC) for the prediction of RoR at 1 year in patients commencing biologics for SBCD.

METHODS

Prospective, multicenter (n = 13) cohort study of patients with active non-stricturing SBCD requiring anti-TNFα or anti-IL-12/23 treatment. We measured mMRI and CRP at baseline and post-induction (visit 2: 12-30 weeks), and FC in a subset. RoR was assessed at 1 year using clinical and structural magnetic resonance enterography parameters. We compared sensitivity, specificity, and area under the receiver operating characteristic curve (ROC-AUC) of changes in mMRI and CRP to predict RoR at 1 year. Secondary outcomes compared mMRI with FC, and prediction of improved quality of life (QoL).

RESULTS

Eighty-six participants completed all assessments. Stable or improved mMRI at visit 2 was more sensitive than normalization of CRP for RoR (mMRI:71.0%, 95%CI 52.0-85.8; CRP:45.2%, 95%CI 27.3-64.0%, P = .008) but less specific (mMRI:30.9%, 95%CI 19.1-44.8; CRP:67.3%, 95%CI 53.3-79.3%, P < .001). There was no significant difference in ROC-AUC (mMRI:0.48; CRP:0.53, P = .65). Similar results were obtained for FC. None of mMRI, CRP, or FC predicted patient QoL at 1 year.

CONCLUSIONS

Although improved mMRI is more sensitive than CRP and FC to predict RoR at 1 year, it is less specific. No factor predicted patient QoL. Motility MRI remains a marker of disease activity at given timepoints.

Comprehensive review of Clostridium difficile infection: Epidemiology, diagnosis, prevention, and treatment

In recent years, nosocomial infections caused by Clostridium difficile (C. difficile) have risen, becoming a leading cause of hospital-acquired diarrhea. The global prevalence of C. difficile infection (CDI) varies across regions and populations. The diagnosis relies primarily on laboratory testing, including toxin, glutamate dehydrogenase, and nucleic acid amplification tests. Treatment strategies for CDI include antimicrobial therapy (e.g., metronidazole, vancomycin, and fidamycin), fecal transplantation, and immunotherapy (e.g., belotozumab), depending on the patient's specificity and severity. This paper reviews recent research on CDI's epidemiological characteristics, risk factors, diagnosis, treatment, and prevention, aiming to support hospitals and public health initiatives in implementing effective detection, prevention, and treatment strategies.

Model Predicting Survival in Intermediate-Stage HCC Patients Reclassified for TACE Based on the 2022 BCLC Criteria

Background/Objectives: The Barcelona Clinic Liver Cancer (BCLC) staging system for hepatocellular carcinoma (HCC) was updated in 2022 to refine patient stratification, particularly in patients with intermediate-stage (BCLC B) HCC. Although transarterial chemoembolization (TACE) remains a key treatment for these patients, there is no prognostic model for survival outcomes based on the pretreatment factors of patients who meet the updated 2022 BCLC indications for TACE. The aim of this study was to develop a pretreatment risk model predicting overall survival (OS) in patients with intermediate-stage HCC and reclassified as candidates for TACE according to the updated 2022 BCLC criteria. Methods: This retrospective study included 658 HCC patients treated with first-line TACE according to the updated BCLC 2022 guidelines. Pretreatment factors such as the Child-Pugh score, tumor burden (up-to-11 criteria), bilobar tumor involvement, and serum alpha-fetoprotein (AFP) levels were analyzed. Cox proportional hazards models were used to identify significant predictors of OS, with these factors subsequently incorporated into a risk prediction model. Results: Significant predictors of OS included Child-Pugh score ≥ 7, bilobar tumor involvement, beyond up-to-11 criteria, and AFP ≥ 400 ng/mL. A risk model was developed using these factors, stratifying patients into low-, intermediate-, and high-risk groups. The median OS in the low-, intermediate-, and high-risk groups was 53, 35, and 21 months, respectively. Conclusions: The proposed pretreatment risk prediction model may be useful for predicting OS and guiding TACE candidacy in intermediate-stage HCC patients based on the updated 2022 BCLC guidelines.

Colon Cancer Screening, Surveillance, and Treatment: Novel Artificial Intelligence Driving Strategies in the Management of Colon Lesions

Colonoscopy, a crucial procedure for detecting and removing colorectal polyps, has seen transformative advancements through the integration of artificial intelligence, specifically in computer-aided detection (CADe) and diagnosis (CADx). These tools enhance real-time detection and characterization of lesions, potentially reducing human error, and standardizing the quality of colonoscopy across endoscopists. CADe has proven effective in increasing adenoma detection rate, potentially reducing long-term colorectal cancer incidence. However, CADe's benefits are accompanied by challenges, such as potentially longer procedure times, increased non-neoplastic polyp resections, and a higher surveillance burden. CADx, although promising in differentiating neoplastic and non-neoplastic diminutive polyps, encounters limitations in accuracy, particularly in the proximal colon. Real-world data also revealed gaps between trial efficacy and practical outcomes, emphasizing the need for further research in uncontrolled settings. Moreover, CADx limited specificity and binary output underscore the necessity for explainable artificial intelligence to gain endoscopists' trust. This review aimed to explore the benefits, harms, and limitations of artificial intelligence for colon cancer screening, surveillance, and treatment focusing on CADe and CADx systems for lesion detection and characterization, respectively, while addressing challenges in integrating these technologies into clinical practice.

Integrating CT Radiomics and Clinical Features to Optimize TACE Technique Decision-Making in Hepatocellular Carcinoma

BACKGROUND/OBJECTIVES

To develop a decision framework integrating computed tomography (CT) radiomics and clinical factors to guide the selection of transarterial chemoembolization (TACE) technique for optimizing treatment response in non-resectable hepatocellular carcinoma (HCC).

METHODS

A retrospective analysis was performed on 151 patients [33 conventional TACE (cTACE), 69 drug-eluting bead TACE (DEB-TACE), 49 degradable starch microsphere TACE (DSM-TACE)] who underwent TACE for HCC at a single tertiary center. Pre-TACE contrast-enhanced CT images were used to extract radiomic features of the TACE-treated liver tumor volume. Patient clinical and laboratory data were combined with radiomics-derived predictors in an elastic net regularized logistic regression model to identify independent factors associated with early response at 4-6 weeks post-TACE. Predicted response probabilities under each TACE technique were compared with the actual techniques performed.

RESULTS

Elastic net modeling identified three independent predictors of response: radiomic feature "Contrast" (OR = 5.80), BCLC stage B (OR = 0.92), and viral hepatitis etiology (OR = 0.74). Interaction models indicated that the relative benefit of each TACE technique depended on the identified patient-specific predictors. Model-based recommendations differed from the actual treatment selected in 66.2% of cases, suggesting potential for improved patient-technique matching.

CONCLUSIONS

Integrating CT radiomics with clinical variables may help identify the optimal TACE technique for individual HCC patients. This approach holds promise for a more personalized therapy selection and improved response rates beyond standard clinical decision-making.

Delayed bleeding after endoscopic sphincterotomy in patients receiving anticoagulants

Delayed bleeding after endoscopic sphincterotomy (EST) constitutes a significant adverse event, occurring in ~0.5-5% of patients. The number of patients receiving anticoagulants to prevent cardiovascular and cerebrovascular disease has increased with the aging society worldwide; however, anticoagulants (direct oral anticoagulants [DOACs] and warfarin) are one of the most major risk factors for postprocedure bleeding. This review investigated post-EST bleeding in anticoagulant users, focusing on risk factors, clinical guidelines, pharmacological characteristics, and the future of post-EST bleeding. Several clinical guidelines for antithrombotic drug users have been established to prevent postprocedure bleeding; nevertheless, the risk of bleeding is believed to be several times higher than for nondrug users, regardless of clinical guideline compliance. The major problem in this field is that patients who experience delayed bleeding are often receiving multiple antithrombotic drugs, and no parameters that can accurately monitor the anticoagulant effect of DOACs have been identified. Therefore, identifying patients with a generally high-risk of postprocedure bleeding is crucial. Recently, the plasma level and antifactor Xa activity of factor Xa inhibitors have been investigated in relation to the risk of major bleeding in users. Similar to the prothrombin time-international normalized ratio for warfarin, plasma levels, and antifactor Xa activity may be useful parameters for monitoring the anticoagulant effect and identifying DOAC users at higher risk of postprocedure bleeding, including post-EST bleeding. Future studies should stratify the risk of post-EST delayed bleeding based on a scoring system to prevent this complication.

EUS-based intratumoral and peritumoral machine learning radiomics analysis for distinguishing pancreatic neuroendocrine tumors from pancreatic cancer

Objectives

This study aimed to develop and validate intratumoral, peritumoral, and combined radiomic models based on endoscopic ultrasonography (EUS) for retrospectively differentiating pancreatic neuroendocrine tumors (PNETs) from pancreatic cancer.

Methods

A total of 257 patients, including 151 with pancreatic cancer and 106 with PNETs, were retroactively enrolled after confirmation through pathological examination. These patients were randomized to either the training or test cohort in a ratio of 7:3. Radiomic features were extracted from the intratumoral and peritumoral regions from conventional EUS images. Following this, the radiomic features underwent dimensionality reduction through the utilization of the least absolute shrinkage and selection operator (LASSO) algorithm. Six machine learning algorithms were utilized to train prediction models employing features with nonzero coefficients. The optimum intratumoral radiomic model was identified and subsequently employed for further analysis. Furthermore, a combined radiomic model integrating both intratumoral and peritumoral radiomic features was established and assessed based on the same machine learning algorithm. Finally, a nomogram was constructed, integrating clinical signature and combined radiomics model.

Results

107 radiomic features were extracted from EUS and only those with nonzero coefficients were kept. Among the six radiomic models, the support vector machine (SVM) model had the highest performance with AUCs of 0.853 in the training cohort and 0.755 in the test cohort. A peritumoral radiomic model was developed and assessed, achieving an AUC of 0.841 in the training and 0.785 in the test cohorts. The amalgamated model, incorporating intratumoral and peritumoral radiomic features, exhibited superior predictive accuracy in both the training (AUC=0.861) and test (AUC=0.822) cohorts. These findings were validated using the Delong test. The calibration and decision curve analyses (DCA) of the combined radiomic model displayed exceptional accuracy and provided the greatest net benefit for clinical decision-making when compared to other models. Finally, the nomogram also achieved an excellent performance.

Conclusions

An efficient and accurate EUS-based radiomic model incorporating intratumoral and peritumoral radiomic features was proposed and validated to accurately distinguish PNETs from pancreatic cancer. This research has the potential to offer novel perspectives on enhancing the clinical utility of EUS in the prediction of PNETs.

Health inequalities in hepatocellular carcinoma surveillance, diagnosis, treatment, and survival in the United Kingdom: a scoping review

BACKGROUND

Hepatocellular carcinoma (HCC) remains a deadly cancer in the UK despite advancements in curative therapies. Societal conditions and health inequalities influence the development of chronic liver disease and outcomes from complications including HCC. Scoping this emergent evidence-base is required to inform research and solutions for the NHS.

METHODS

A PRISMA scoping review was performed up to September 2023. Articles exploring health inequalities in HCC involving the UK population were included.

RESULTS

This review has characterised axes of health inequality and their impact across the HCC care continuum in the UK. Studies predominantly employed a cohort design or population-based analyses, with meta-analyses of surveillance utilisation including only a single UK study. These methodologies provided an appropriate lens to understand longitudinal trends and identify disadvantaged groups. However, important evidence gaps remain, including exploration of patient perspectives, intersectional analyses, and statistical measures of socioeconomic inequity in HCC.

CONCLUSIONS

HCC is a rapidly growing cause of cancer mortality and disproportionally affects underserved groups, presenting a major public health concern. Further research is required to innovate and evaluate surveillance and management pathways to reduce systemic inequities. Direction is needed at the national level to improve prevention, early diagnosis and access to curative treatment.

Mailed Outreach and Patient Navigation for Colorectal Cancer Screening Among Rural Medicaid Enrollees: A Cluster Randomized Clinical Trial

Importance

Approximately 60 million adults live in rural regions of the US, which historically have low rates of colorectal cancer (CRC) screening and follow-up. Rural residents enrolled in Medicaid have particularly low CRC screening and follow-up rates.

Objective

To determine the effectiveness and implementation of a collaborative Medicaid health plan-clinic program of mailed fecal immunochemical test (FIT) outreach and patient navigation to colonoscopy following an abnormal FIT result when implemented in rural clinics as part of standard care.

Design, Setting, and Participants

This cluster randomized clinical trial was conducted at 28 rural clinic units in Oregon affiliated with 3 Medicaid health plans. The clinics were randomized to the intervention (n = 14) or to usual care (n = 14). Participants were Medicaid enrollees (aged 50-75 years) due for CRC screening. The intervention was delivered from May 11, 2021, through June 4, 2022, and analyses were performed from June 2023 through September 2024.

Intervention

The stepwise intervention involved (1) mailed FIT outreach and (2) patient navigation to colonoscopy following an abnormal FIT result. Implementation support included practice facilitation, training, collaborative learning, and patient tracking tools.

Main Outcomes and Measures

The primary effectiveness outcome was completion of any CRC screening within 6 months of eligibility determination. An additional effectiveness outcome was follow-up colonoscopy completion within 6 months of an abnormal FIT result. Implementation was measured as (1) the proportion of intervention-eligible enrollees who were mailed an FIT and who were sent an advance notification or reminder and (2) the proportion with an abnormal FIT result who were offered patient navigation.

Results

This study included 5614 Medicaid enrollees (2613 in intervention clinics and 3001 in usual care clinics). Enrollees had a mean (SD) age of 58.2 (5.5) years; most (4940 [88.0%]) were aged 50 to 64 years. A total of 2948 enrollees (52.5%) were female, 325 (6.2%) were Hispanic and 3774 (67.2%) were White, and 4457 (79.4%) lived in rural regions. Compared with Medicaid enrollees in usual care clinics, enrollees in intervention clinics had a higher adjusted 6-month proportion of any CRC screening completion (11.8% vs 4.5%; difference, 7.3 [95% CI, 5.3-9.2] percentage points). Implementation was 100% (all 1489 intervention-eligible enrollees) for mailed FIT outreach, 88.5% for advance notification, 78.1% for reminders, and 57.9% for patient navigation.

Conclusions and Relevance

In this cluster randomized clinical trial of rural clinics, mailed FIT outreach and patient navigation boosted participation in CRC screening among Medicaid enrollees. More efforts are needed to address low participation in both FIT testing and follow-up colonoscopy.

Trial Registration

ClinicalTrials.gov Identifier: NCT04890054.

Safety and efficacy of ciprofol versus propofol for gastrointestinal endoscopy: a meta-analysis

BACKGROUND

The role of ciprofol as a novel anesthetic in gastrointestinal endoscopic surgery is unclear. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of ciprofol for gastrointestinal endoscopy in patients aged over 65 years and under 65 years, aiming to provide evidence-based information for clinical decision-making.

METHODS

We conducted a search for RCTs(randomized controlled trials) comparing ciprofol and propofol in gastrointestinal endoscopy on databases including PubMed, Embase, Cochrane Library, Web of Science, (China National Knowledge Infrastructure)CNKI, Wanfang, and Vipro Chinese Journal Service up to September 15, 2024. The required information was screened and extracted, and the quality of the included research literatures was assessed using the Cochrane Collaboration risk of bias assessment tool, and Meta-analysis of outcome metrics was performed using Revman 5.4 and Stata software.

RESULTS

A total of 17 RCTs involving 2800 patients were included, with 1,450 patients in the ciprofol group and 1350 patients in the propofol group. The results of the meta-analysis indicated that there was no statistically significant difference in the sedation success rate or recovery time between the two groups across all age categories. In patients under 65 years old, the induction time of the ciprofol group (MD = 0.41 min, 95%CI: 0.04 min ∼ 0.78 min, P = 0.03) was longer than that in the propofol group. The incidences of hypotension (OR = 0.48, 95%CI: 0.32 ∼ 0.72, P = 0.004), bradycardia (OR = 0.66, 95%CI: 0.49 ∼ 0.87, P = 0.004), injection pain (OR = 0.08, 95%CI: 0.05 ∼ 0.15, P<0.0001), respiratory depression (OR = 0.21, 95%CI: 0.15 ∼ 0.30, P<0.0001), and hypoxemia (OR = 0.29, 95%CI: 0.20 ∼ 0.43, P<0.0001), in the ciprofol group were much lower than those in the propofol group.

CONCLUSION

Meta-analysis results indicate that, across various age groups, ciprofol demonstrates a higher safety profile and effectively reduces the incidence of postoperative (ADRs)adverse reactions compared to propofol. However, there is no significant difference in the sedative effects of the two agents. This study categorized elderly patients into subgroups, thereby providing a foundation for the application of ciprofol in gastrointestinal examinations of elderly patients. Consequently, we propose that ciprofol may serve as a safer alternative to intravenous anesthesia compared to propofol; However, this conclusion requires further validation through high-quality studies.

Colon obstruction due to sunflower seed bezoar: A case report

INTRODUCTION

This case report aims to present a rare case of colon obstruction caused by a bezoar in a 15-year-old teenager. The significance of this case lies in the rarity of such obstructions and the necessity for early diagnosis and appropriate intervention to optimize patient outcomes.

PRESENTATION OF CASE

A 15-year-old teenager presented with colicky abdominal pain, abdominal distension, nausea, vomiting, and rectal bleeding for three days. Initial investigations yielded normal results, but a digital rectal examination and abdominal X-ray suggested colon obstruction. The patient underwent surgical consultation and emergent laparotomy, during which a bezoar was identified and successfully removed endoscopically. Colonoscopy revealed that the bezoar was composed of shelled sunflower seeds, which correlated with the patient's dietary history.

DISCUSSION

This case highlights the rarity of bezoars causing colon obstruction. Early recognition and appropriate intervention are crucial for optimizing patient outcomes and preventing complications associated with colon obstruction.

CONCLUSION

This report highlights the importance of considering bezoars as a differential diagnosis in patients with colon obstruction. Early identification and treatment can prevent serious complications and improve clinical outcomes.

Significance of frailty in mortality and complication after hepatectomy for patients with liver cancer: a systematic review and meta-analysis

BACKGROUND

Frailty has been associated with increased mortality and complications among liver cancer patients. However, the frailty prevalence and outcomes in frail populations with primary liver cancer have not been systematically validated.

METHODS

Embase, PubMed, Scopus, and Web of Science were searched for eligible studies that explored the prevalence and impact of frailty in liver cancers from inception until October 26, 2023. The pooled prevalence, hazard ratio (HR), and odds ratio (OR) corresponding to 95 % confidence intervals (CI) in mortality and major complication estimates were conducted.

RESULTS

A total of 18 studies containing 38,157 primary liver cancer patients were included. The prevalence of frailty in liver cancer was 35 % (95 % CI = 25-46; p = 0.000). Frailty was associated with an increased hazard ratio for 30-day mortality (HR = 7.03; 95 % CI = 0.71-69.45; p = 0.97) and 90-day mortality (HR = 4.59; 95 % CI = 1.76-11.95; p = 0.38). Furthermore, frailty was associated with an increased odds ratio for major complications in liver cancer patients (OR = 4.01; 95 % CI = 2.25-7.14; p = 0.49).

CONCLUSION

Frailty is frequent in liver cancer patients and may predict adverse outcomes in primary liver cancer patients with hepatectomy. Our findings highlight the importance of frailty assessment in this population.

Practical management of severe acute pancreatitis

Acute pancreatitis (AP) represents one of the most common reasons for hospital admission and intensive care treatment in internal medicine. The incidence of AP is increasing, posing significant financial burden on healthcare systems due to the necessity for frequent medical interventions. Severe acute pancreatitis (SAP) is a potentially life-threatening condition with substantial morbidity and mortality. The management of SAP requires prolonged hospitalization and the expertise of a multidisciplinary team, comprising emergency physicians, intensivists, internists, gastroenterologists, visceral surgeons, and experts in nutrition, infectious disease, endoscopy, as well as diagnostic and interventional radiology. Effective management and beneficial patient outcomes depend on continuous interdisciplinary collaboration. This review synthesizes recent evidence guiding the practical management of SAP, with a particular focus on emergency and intensive care settings. Both established as well as new diagnostic and therapeutic paradigms are highlighted, including workup, risk stratification, fluid management, analgesia, nutrition, organ support, imaging modalities and their timing, along with anti-infective strategies. Furthermore, the review explores interventions for local and vascular complications of SAP, with particular attention to the indications, timing and selection between endoscopic (both endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS)), percutaneous and surgical approaches. Similarly, the management of biliary AP due to obstructive gallstones, including the imaging, timing of ERCP and cholecystectomy, are discussed. By integrating new evidence with relevant guidance for everyday clinical practice, this review aims to enhance the interdisciplinary approach essential for improving outcomes in SAP management.

Microwave ablation versus radiofrequency ablation for hepatocellular carcinoma in patients with decompensated cirrhosis

BACKGROUND

The efficacy of microwave ablation (MWA) and radiofrequency ablation (RFA) in hepatocellular carcinoma (HCC) patients with decompensated cirrhosis remains unclear.

METHODS

A total of 315 patients with decompensated cirrhosis and HCC who underwent MWA or RFA were recruited. Recurrence beyond the Milan criteria (RBM), local tumor progression (LTP), overall survival (OS), and complications were evaluated and compared.

RESULTS

After propensity score matching, the overall liver-related complication rates were 12.1 % in the current study. The cumulative RBM rates were lower in patients treated with MWA compared to those treated with RFA (21.9 % vs. 23.4 % at 1 year; 42.3 % vs. 66.8 % at 5 years; p = 0.016). In addition, lower cumulative rates of LTP were found in patients treated with MWA compared to those treated with RFA (6.2 % vs. 19.9 % at 1 year; 14.7 % vs. 27.8 % at 3 years; p = 0.032). The OS rates at 1 and 5 years were 89.9 % and 58.9 % in the MWA group, and 80.7 %, and 38.9 % in the RFA group, respectively (p = 0.105).

CONCLUSION

HCC patients with decompensated cirrhosis can undergo MWA or RFA with acceptable mortality, morbidity and liver-rated complications rates. MWA demonstrates superiority over RFA in tumor control.

Subclinical pancreatic exocrine insufficiency is associated with osteopathy in patients with chronic pancreatitis: Implications for management

BACKGROUND AND AIMS

Patients with chronic pancreatitis (CP) may develop pancreatic exocrine insufficiency (PEI) but data regarding subclinical PEI are scarce. Our objective was to detect subclinical PEI in patients with CP and its functional consequences.

METHODS

We prospectively included patients with CP from April 2018-December 2021. Mild PEI and severe PEI were diagnosed if fecal elastase (FE) was 100-200 μg/g and <100 μg/g stool respectively. Vitamin levels and DEXA scan were done to assess functional consequences of PEI. Presence of subclinical PEI in CP (low FE-1 but without steatorrhea) with consequent osteopathy was the primary outcome.

RESULTS

Of 120 patients with CP, subclinical PEI (low FE-1 but no steatorrhea) was present in 84/120(70%) patients: 6/8(75%) in early CP, 41/53(77%) in definite CP and 37/55(67.2%) in advanced CP. Overall, 72.1% patients had osteopathy including 53(62%) among patients with subclinical PEI. There was no difference in osteopathy between subclinical and severe PEI. Patients with severe PEI had lower vitamin A levels as compared to mild PEI and no PEI patients [1.3 ± 0.5 mg/ml vs. 1.7 ± 0.6 mg/ml vs. 1.8 ± 0.5 mg/ml; p = 0.04]. There was no difference in vitamin D levels. Osteopathy was present in 40/56 (71.4%) in advanced, 26/56 (46.4%) in definite and 2/8 (25%) in early CP patients (p = 0.09). On multivariable analysis, patients with advanced CP had the higher risk of osteopathy (odds ratio 7.6, 95% CI 1.9-29.7).

CONCLUSIONS

Subclinical PEI was present even in early CP with increased risk of osteopathy and fat-soluble vitamin deficiency.

Association of anaesthesia-directed sedation with unplanned discharge to a nursing home following non-ambulatory interventional radiology and endoscopic procedures: a retrospective cohort study

INTRODUCTION

Interventional radiology procedures and endoscopies are performed commonly worldwide, often necessitating pharmacological sedation to optimise patient comfort. It is unclear to what extent non-anaesthetists should provide procedural sedation.

METHODS

We studied adult patients who previously lived independently and underwent a non-ambulatory interventional radiology or gastroenterology procedure under anaesthetist-directed or non-anaesthetist-directed sedation at a large healthcare network. The primary outcomes were postprocedural adverse discharge to a nursing home and postprocedural duration of hospital stay.

RESULTS

Among 22,868 patients included, 15,168 (66.3%) and 7700 (33.7%) underwent anaesthetist-directed sedation and non-anaesthetist-directed sedation, respectively. Of all patients receiving anaesthetist-directed sedation, 9.2% experienced adverse discharge to a nursing home compared with 21.3% undergoing non-anaesthetist-directed sedation. Anaesthetist-directed sedation was associated with reduced risk of adverse discharge to a nursing home (adjusted relative risk 0.54, 95%CI 0.45-0.63, p < 0.001, adjusted risk difference -4.6%, 95%CI -5.8 to -3.4, p < 0.001) and a shorter postprocedural duration of hospital stay (median (IQR [range]) 2 (1-6 [0-315]) days vs. 5 (2-12 [0-268]) days; adjusted model estimate 0.84, 95%CI 0.79-0.89, p < 0.001). The lower risk of adverse discharge to a nursing home and shorter duration of hospital stay in patients undergoing anaesthetist-directed sedation was reproduced in an instrumental variable analysis (adjusted risk difference -4.3%, 95%CI -8.4 to -0.1, p = 0.043; and -1.41 days, 95%CI -1.43 to -1.41 days, p < 0.001, respectively). Among patients undergoing anaesthetist-directed sedation the mean (SD) proportion of missing blood pressure measurements was lower (0.7 (4.9) % vs. 8.0 (14.6) %, p < 0.001), which mediated the effect of anaesthetist-directed sedation on adverse discharge.

DISCUSSION

Among patients undergoing a non-ambulatory interventional radiology procedure or a gastrointestinal endoscopy, anaesthetist-directed sedation is associated with a reduced risk of adverse discharge to a nursing home and a shorter duration of hospital stay.

Prediction of treatment response and outcome of transarterial chemoembolization in patients with hepatocellular carcinoma using artificial intelligence: A systematic review of efficacy

PURPOSE

To perform a systematic literature review of the efficacy of different AI models to predict HCC treatment response to transarterial chemoembolization (TACE), including overall survival (OS) and time to progression (TTP).

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines until May 2, 2024.

RESULTS

The systematic review included 23 studies with 4,486 HCC patients. The AI algorithm receiver operator characteristic (ROC) area under the curve (AUC) for predicting HCC response to TACE based on mRECIST criteria ranged from 0.55 to 0.97. Radiomics-models outperformed non-radiomics models (AUCs: 0.79, 95 %CI: 0.75-0.82 vs. 0.73, 0.61-0.77, respectively). The best ML methods used for the prediction of TACE response for HCC patients were CNN, GB, SVM, and RF with AUCs of 0.88 (0.79-0.97), 0.82 (0.71-0.89), 0.8 (0.60-0.87) and 0.8 (0.55-0.96), respectively. Of all predictive feature models, those combining clinic-radiologic features (ALBI grade, BCLC stage, AFP level, tumor diameter, distribution, and peritumoral arterial enhancement) had higher AUCs compared with models based on clinical characteristics alone (0.79, 0.73-0.89; p = 0.04 for CT + clinical, 0.81, 0.75-0.88; p = 0.017 for MRI + clinical versus 0.6, 0.55-0.75 in clinical characteristics alone).

CONCLUSION

Integrating clinic-radiologic features enhances AI models' predictive performance for HCC patient response to TACE, with CNN, GB, SVM, and RF methods outperforming others. Key predictive clinic-radiologic features include ALBI grade, BCLC stage, AFP level, tumor diameter, distribution, and peritumoral arterial enhancement. Multi-institutional studies are needed to improve AI model accuracy, address heterogeneity, and resolve validation issues.

Placenta hIGF1 nanoparticle treatment in guinea pigs mitigates FGR-associated fetal sex-dependent effects on liver metabolism-related signaling pathways

Fetal development in an adverse in utero environment significantly increases the risk of developing metabolic diseases in later life, including dyslipidemia, nonalcoholic fatty liver diseases, and diabetes. The aim of this study was to determine whether improving the in utero fetal growth environment with a placental nanoparticle gene therapy would ameliorate fetal growth restriction (FGR)-associated dysregulation of fetal hepatic lipid and glucose metabolism-related signaling pathways. Using the guinea pig maternal nutrient restriction (MNR) model of placental insufficiency and FGR, placenta efficiency and fetal weight were significantly improved following three administrations of a nonviral polymer-based nanoparticle gene therapy to the placenta from mid-pregnancy (gestational day 35) until gestational day 52. The nanoparticle gene therapy transiently increased expression of human insulin-like growth factor 1 (hIGF1) in placenta trophoblast. Fetal liver tissue was collected near-term at gestational day 60. Fetal sex-specific differences in liver gene and protein expression of profibrosis and glucose metabolism-related factors were demonstrated in sham-treated FGR fetuses but not observed in FGR fetuses who received placental hIGF1 nanoparticle treatment. Increased plasma bilirubin, an indirect measure of hepatic activity, was also demonstrated with placental hIGF1 nanoparticle treatment. We speculate that the changes in liver gene and protein expression and increased liver activity that result in similar expression profiles to appropriately growing control fetuses might confer protection against increased susceptibility to aberrant liver physiology in later life. Overall, this work opens avenues for future research assessing the translational prospect of mitigating FGR-induced metabolic derangements.NEW & NOTEWORTHY A placenta-specific nonviral polymer-based nanoparticle gene therapy that improves placenta nutrient transport and near-term fetal weight ameliorates growth restriction-associated changes to fetal liver activity, and cholesterol and glucose/nutrient homeostasis genes/proteins that might confer protection against increased susceptibility to aberrant liver physiology in later life. This knowledge may have implications toward removing predispositions that increase the risk of metabolic diseases, including diabetes, dyslipidemia, and nonalcoholic fatty liver disease in later life.

Optimizing Colonoscopy Preparation in Autistic Children: A Comparative Study of Hypertonic Sugar Saline and Normal Saline Enemas

OBJECTIVE

This study evaluates the effectiveness of combining oral polyethylene glycol electrolyte solution with hypertonic sugar saline enema for colonoscopy preparation in autistic children.

METHODS

Clinical data of 58 children with autism who underwent fecal bacteria transplantation and transendoscopic enteral tubing (TET) catheterization at the hospital were retrospectively analyzed. Participants were allocated into 2 groups: a control group (26 children) and an observation group (32 children), differentiated by their intestinal preparation protocols. The control group was administered oral polyethylene glycol combined with normal saline enema, whereas the observation group was given oral polyethylene glycol combined with hypertonic sugar saline enema. The Boston Bowel Preparation Scale (BBPS) was used to score intestinal cleanliness. Differences in intestinal cleanliness and colonoscopy duration between the 2 groups were compared.

RESULTS

The group treated with hypertonic sugar saline enema exhibited significantly higher BBPS scores (6.78 ± 0.83) and an intestinal passage rate of 96.86%, which were statistically significant compared with the control group (P < 0.05). In addition, the colonoscopy duration was notably shorter in the observation group (14.03 ± 4.86 minutes) compared with the control group (P < 0.05).

CONCLUSION

Our findings suggest that an oral polyethylene glycol electrolyte solution combined with a hypertonic sugar saline enema is a more effective preparation method for colonoscopy in autistic children.

The Chinese Society of Clinical Oncology (CSCO): Clinical guidelines for the diagnosis and treatment of colorectal cancer, 2024 update

The 2024 updates of the Chinese Society of Clinical Oncology (CSCO) Clinical Guidelines for the diagnosis and treatment of colorectal cancer emphasize standardizing cancer treatment in China, highlighting the latest advancements in evidence-based medicine, healthcare resource access, and precision medicine in oncology. These updates address disparities in epidemiological trends, clinicopathological characteristics, tumor biology, treatment approaches, and drug selection for colorectal cancer patients across diverse regions and backgrounds. Key revisions include adjustments to evidence levels for intensive treatment strategies, updates to regimens for deficient mismatch repair (dMMR)/ microsatellite instability-high (MSI-H) patients, proficient mismatch repair (pMMR)/ microsatellite stability (MSS) patients who have failed standard therapies, and rectal cancer patients with low recurrence risk. Additionally, recommendations for digital rectal examination and DNA polymerase epsilon (POLE)/ DNA polymerase delta 1 (POLD1) gene mutation testing have been strengthened. The 2024 CSCO Guidelines are based on both Chinese and international clinical research, as well as expert consensus, ensuring their relevance and applicability in clinical practice, while maintaining a commitment to scientific rigor, impartiality, and timely updates.