Treatment strategies for small pancreatic neuroendocrine tumors (PNETs) <2 cm in size are still under debate. The feasibility and safety of EUS-guided ethanol ablation (EUS-EA) have been ...demonstrated. However, sample sizes in previous studies were small with no comparative studies on surgery. Therefore, we aimed to compare the safety and long-term outcomes of EUS-EA with those of surgery for the management of nonfunctioning small PNETs.
We retrospectively reviewed patients with PNETs who were managed by EUS-EA (from 2011 to 2018) and surgery (from 2000 to 2018) at Asan Medical Center. Propensity score matching (PSM) was performed to increase comparability. The primary outcome was early and late major adverse events (Clavien-Dindo grade ≥III) after treatment. Secondary outcomes were 10-year overall (OS) and disease-specific survival (DSS) rates, length of hospital stay, and development of endocrine pancreatic insufficiency.
Of all patients, 97 and 188 patients were included in the EUS-EA and surgery groups, respectively. PSM created 89 matched pairs. EUS-EA was associated with a significantly lower rate of early major adverse events (0% vs 11.2%, P = .003). Late major adverse events occurred more frequently after surgery, with no significant difference between groups (3.4% vs 10.1%, P = .07). Both treatment modalities showed comparable 10-year OS and DSS rates. The length of hospital stay was significantly shorter in the EUS-EA group (4 days vs 14.1 days, P < .001), and endocrine pancreatic insufficiency was less common after EUS-EA than after surgery (33.3% vs 48.6%, P = .121).
EUS-EA had fewer adverse events and a shorter hospital stay with similar OS and DSS rates compared with surgery, suggesting that EUS-EA may be a preferred alternative to surgical resection in selected patients with nonfunctioning small PNETs.
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The guidewire is an essential accessory in ERCP. Although rare, guidewires can cause complications, such as subcapsular hepatic hematoma, perforation, knotting, fracture, and impaction, during ERCP. ...This report describes a guidewire impaction during the endoscopic treatment of a patient with symptomatic chronic pancreatitis. The methods used to treat guidewire impaction are not well known. In the present case, the impacted guidewire was retrieved by inserting another guidewire and dilating the space adjacent to it. Endoscopists should check for the free movement of the guidewire before stent deployment. Additionally, it is important to ask for help from experienced senior staff to overcome any challenges during the procedure. In conclusion, endoscopists should be aware of the possibility of a guidewire impaction during ERCP.
AIM To investigate the temporal trends in the misdiagnosis rate between Crohn’s disease(CD) and intestinal tuberculosis(ITB) in South Korea. METHODS We retrospectively reviewed the medical records of ...patients managed for CD or ITB at Asan Medical Center, a tertiary referral hospital, Seoul, Korea between 1996 and 2014. The temporal trends in the misdiagnosis rates between the two diseases were analyzed. The demographic and clinical characteristics were compared between CD patients who were initially misdiagnosed as ITB(final CD group) and vice versa(final ITB group). Final diagnostic criteria for ITB and medication for CD before definite diagnosis of TB were also analyzed in final ITB group.RESULTS In total, 2760 patients were managed for CD and 772 patients for ITB between 1996 and 2014. As well, 494 of the 2760 CD patients(17.9%) were initially misdiagnosed as ITB and 83 of the 772 ITB patients(10.8%) as CD. The temporal trend in misdiagnosing CD as ITB showed a decrease(OR = 0.89, 95%CI: 0.87-0.91, P < 0.001), whereas the temporal trend in misdiagnosing ITB as CD showed an increase(OR = 1.06, 95%CI: 1.01-1.11, P = 0.013). Age at diagnosis, presenting symptoms, and proportion of patients with active/past perianal fistula and active/inactive pulmonary tuberculosis(TB) were significantly different between final CD group and final ITB group. Forty patients(48.2%) in final ITB group were diagnosed by favorable response to empirical anti-TB treatment. Seventeen patients(20.5%) in final ITB group had inappropriately received corticosteroids and/or thiopurines due to misdiagnosis as CD. However, there were no mortalities in both groups. CONCLUSION Cases of CD misdiagnosed as ITB have been decreasing, whereas cases of ITB misdiagnosed as CD have been increasing over the past two decades.
Colorectal mucosa-associated lymphoid tissue (MALT) lymphoma is a rare disease. The purpose of this study was to investigate the clinical and endoscopic features of colorectal MALT lymphoma.
Patients ...diagnosed with colorectal MALT lymphoma at Asan Medical Center from 2002 to 2016 were eligible. Medical records were reviewed to investigate clinical features and treatment outcomes. Endoscopic pictures were assessed to characterize the endoscopic features of colorectal MALT lymphoma.
A total of 51 patients were enrolled. The median age was 60 years (interquartile range, 55-71), and 21 (41%) were men. Twenty-six patients (51%) were asymptomatic. Forty-four patients (86%) were in early disease stages, namely Lugano stages I, II, and IIE. Endoscopic appearances were classified as 4 distinct types: subepithelial tumor type (26 patients, 51%), polyposis type (10 patients, 20%), epithelial mass type (7 patients, 14%), and ileitis type (8 patients, 16%). The rectum (20 patients, 39%) was the most common location, followed by the ileocecal area (15 patients, 30%). An initial endoscopic impression of lymphoma was made in only 7 patients. Forceps biopsy sampling as the initial tissue acquisition method could histologically diagnose MALT lymphoma in 28 of 35 patients (80%). Polypectomy as the initial histologic diagnosis could diagnose MALT lymphoma in 16 of 16 patients. Progression-free and overall survival rates at 5 years were 92% and 94%, respectively.
Colorectal MALT lymphomas show various endoscopic appearances, complicating the endoscopic suspicion of colorectal MALT lymphoma. The prognosis of colorectal MALT lymphoma was excellent.
Recently, anti-programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) immunotherapy offers promising results for advanced biliary tract cancer (BTC). However, patients show highly ...heterogeneous responses to treatment, and predictive biomarkers are lacking. We performed a systematic review and meta-analysis to assess the potential of PD-L1 expression as a biomarker for treatment response and survival in patients with BTC undergoing anti-PD-1/PD-L1 therapy.
We conducted a comprehensive systematic literature search through June 2023, utilizing the PubMed, EMBASE, and Cochrane Library databases. The outcomes of interest included objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), and overall survival (OS) according to PD-L1 expression. Subgroup analyses and meta-regression were performed to identify possible sources of heterogeneity.
A total of 30 studies was included in the final analysis. Pooled analysis showed no significant differences in ORR (odds ratio OR, 1.56; 95% confidence intervals CIs, 0.94-2.56) and DCR (OR, 1.84; 95% CIs, 0.88-3.82) between PD-L1 (+) and PD-L1 (-) patients. In contrast, survival analysis showed improved PFS (hazard ratio HR, 0.54, 95% CIs, 0.41-0.71) and OS (HR, 0.58; 95% CI, 0.47-0.72) among PD-L1 (+) patients compared to PD-L1 (-) patients. Sensitivity analysis excluding retrospective studies showed no significant differences with the primary results. Furthermore, meta-regression demonstrated that drug target (PD-1
PD-L1), presence of additional intervention (monotherapy
combination therapy), and PD-L1 cut-off level (1%
≥5%) significantly affected the predictive value of PD-L1 expression.
PD-L1 expression might be a helpful biomarker for predicting PFS and OS in patients with BTC undergoing anti-PD-1/PD-L1 therapy. The predictive value of PD-L1 expression can be significantly influenced by diagnostic or treatment variables.
https://www.crd.york.ac.uk/PROSPERO, identifier CRD42023434114.
Background/Purpose
This study aimed to evaluate the feasibility of endoscopic ultrasound (EUS)‐guided antegrade covered stent placement with long duodenal extension (EASL) for malignant distal ...biliary obstruction (MDBO) with duodenal obstruction (DO) or surgically altered anatomy (SAA) after failed endoscopic retrograde cholangiopancreatography (ERCP).
Methods
Outcomes were technical and clinical success, reintervention rate, adverse events, stent patency, and overall survival. Inverse probability of treatment weighting (IPTW) and competing‐risk analysis were performed to compare with conventional EUS‐BD.
Results
Twenty‐five patients (DO, n = 18; SAA, n = 7) were included. The technical and clinical success rates were 96% and 84%, respectively. Reintervention occurred in two patients (8.3%). Adverse events occurred in six patients (24%; two cholangitis, 16%; four mild postprocedural pancreatitis 24% (n = 4/17) in patients with non‐pancreatic cancers). The median patency was 9.4 months, and the overall survival was 2.73 months. After IPTW adjustment, the median patency in the EASL (n = 25) and conventional EUS‐BD (n = 29) were 10.1 and 6.5 months, respectively (P = .018).
Conclusions
EASL has acceptable clinical outcomes with a low reintervention rate but higher rate of postprocedural pancreatitis in patients with non‐pancreatic cancers. Randomized trials comparing EASL and conventional EUS‐BD for MDBO with pancreatic cancers and DO/SAA after failed ERCP are needed to validate our findings.
Highlight
So and colleagues conducted a pilot study of EUS‐guided antegrade covered stent placement with long duodenal extension (EASL) for malignant distal biliary obstruction after failed endoscopic retrograde cholangiopancreatography. EASL resulted in a low reintervention rate. Median patency in EASL and conventional EUS‐guided biliary drainage was 10.1 and 6.5 months, respectively.
For unresectable hilar obstruction, restoring and maintaining biliary ductal patency are crucial for improved survival and quality of life. The endoscopic placement of stents is now a mainstay of its ...treatment, and bilateral stenting is effective for biliary decompression. This study aimed to determine the clinical outcomes of bilateral metal stent placement using large cell-type stents and the clinical predictors of stent dysfunction in patients with malignant hilar obstruction.
We performed a retrospective analysis of patients who underwent bilateral metal stent placement using two large cell-type stents at two academic teaching hospitals between September 2017 and February 2019. The primary outcome was stent dysfunction. Secondary outcomes included predictors related to stent dysfunction and overall survival.
The study included 87 patients who underwent bilateral metal stent placement for malignant hilar obstruction. Technical success and clinical success were achieved in 80 patients (92.0%) and 83 patients (95.4%), respectively. During the follow-up period (median: 201, range: 18-671 days), stent dysfunction occurred in 42 patients (48.3%), and the median stent patency was 199 days (95% confidence interval CI: 181-262). In univariate analysis, age, cholangitis before stent insertion, and subsequent chemotherapy were found to be associated with the cumulative risk of stent dysfunction. In multivariate analysis, cholangitis before stent insertion (hazards ratio HR: 2.26, 95% CI: 1.216-4.209, P = 0.010) and subsequent chemotherapy (HR: 0.250, 95% CI: 0.130-0.482, P<0.001) remained as statically significant factors associated with the cumulative risk of stent dysfunction. The median overall survival was 288 days (95% CI: 230-327).
The bilateral placement of large cell-type stents for malignant hilar obstruction was effective with high technical and clinical success rates and acceptable patency. Cholangitis before stent insertion was associated with shorter patency, and subsequent chemotherapy was associated with longer stent patency.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Endoscopic ultrasound (EUS)-guided fine-needle aspiration was introduced in the early 1990s. EUS has evolved from a diagnostic modality to a therapeutic tool for patients with various pancreatic ...neoplasms. Recent advances in EUS-guided interventions include drainage and ablation. EUS-guided treatment provides a minimally invasive option for patients with pancreatic neoplasms instead of surgery or the percutaneous approach. This review aimed to provide an overview of the current EUS-guided ablation treatments, such as ethanol ablation and radiofrequency ablation, for treating various pancreatic tumors.
Endoscopic snare papillectomy (ESP) has been established as a safe and effective treatment for ampullary adenomas. However, little is known about the optimal post-procedure follow-up period and the ...role of routine endoscopic surveillance biopsy following ESP. We aimed to evaluate patient adherence to a 5-year endoscopic surveillance and routine biopsy protocol after ESP of ampullary adenoma.
We reviewed our prospectively collected database (
= 98), all members of which underwent ESP for ampullary lesions from January 2011 to December 2016, for the evaluation of long-term outcomes. The primary outcome was the rate of patient adherence to 5-year endoscopic surveillance following ESP. The secondary outcomes were the diagnostic yield of routine endoscopic biopsy, recurrence rate, and adverse events after endoscopic surveillance in the 5-year follow-up (3-month, 6-month, and every 1 year).
A total of 19 patients (19.4%) experienced recurrence during follow-up, all of these patients experienced recurrence within 3 years of the procedure (median 217 days, range 69-1083). The adherence rate for patients with sporadic ampullary adenoma were 100%, 93.5%, and 33.6% at 1, 3, and 5 years after ESP, respectively. The diagnostic yield of routine endoscopic biopsy without macroscopic abnormality was 0.54%. Pancreatitis occurred in four patients (4%, 3 mild, 1 moderate) after surveillance endoscopic biopsy without macroscopic abnormality.
Given the low 5-year adherence rate and diagnostic yield of routine endoscopic biopsy with risk of pancreatitis, optimal surveillance intervals according to risk stratification (low grade vs. high grade adenoma/intramucosal adenocarcinoma) may be required to improve patient adherence, and routine biopsy without macroscopic abnormality may not be recommended.
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