Abstract : The detection rate of gastrointestinal subepithelial lesions (SELs) has recently increased with the rise in screening endoscopies. Presumptive diagnoses can be made based on endoscopic features such as color, consistency, size, mobility, shape, and location, prior to definitive histologic diagnoses. For a more accurate differential diagnosis of SELs, endoscopic ultrasonography (EUS) may be necessary. EUS enables the identification of SEL characteristics like the layer of origin, exact size, depth of invasion, echogenicity, and borderline. It can also assess regional lymph node metastases. The behavior and treatment strategies for gastrointestinal SELs vary according to the characteristics of the tumor and the affected site. Neuroendocrine tumors (NETs), a type of SEL with malignant potential, can occur anywhere in the gastrointestinal tract, but are most commonly found in the rectum. Factors that increase the risk of local and distant metastases of rectal NETs include tumor size, involvement of the muscularis propria, differentiation index, and lymphovascular invasion. Therefore, EUS can assist in determining therapeutic strategies and predicting prognosis by measuring the size and depth of invasion of rectal NETs and regional lymph node metastases. However, its role in tissue acquisition is limited in the case of rectal NETs. This review focuses on the clinical applications of EUS imaging in diagnosing and treating rectal NETs.
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Abstract : In recent years, the treatment of metastatic colorectal cancer (mCRC) has dramatically changed thanks to the advent of new drugs called molecular targeted therapies such as anti-vascular endothelial growth factor (anti-VEGF) and anti-epidermal growth factor (anti-EGFR). Bevacizumab, aflibercept and ramucirumab which belong to the first category, have been used for many years in clinical practice, achieving improvements in progression- free survival and overall survival in many phase III trials. These agents act by blocking the growth of the tumor vascular bed via the inhibition of neoangiogenesis. This review summarizes all available data in the literature on bevacizumab, aflibercept, and ramucirumab and describes their use in the continuum of care of mCRC.
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Abstract : Background: Surgically altered anatomy remains a challenge when performing advanced endoscopic procedures, including endoscopic retrograde cholangiopancreatography (ERCP). While ERCP maintains a success rate of 90% to 95% in patients with native anatomy, the data are less robust for patients with post-pancreaticoduodenectomy (PD) anatomy. We conducted a retrospective analysis of the technical success (TS) and clinical success (CS) rates of ERCP in post-PD patients. In addition, we describe our experience using novel rigidizing overtubes to facilitate post-PD ERCP. Methods: Patients with PD referred to our institution between 2006 and 2021 for ERCP were included. Major outcomes included the TS rate (successful biliary intervention) and the CS rate (improvement in patient symptomatology with or without normalization of bilirubin levels). Results: In total, 47 patients underwent 102 ERCPs for biliary (n = 98) and pancreatic (n = 4) indications. The overall TS and CS rates were 82.4% and 75.5%, respectively. Rigidizing overtubes were utilized in 5 patients who underwent 11 ERCPs, with TS and CS rates of 90.9% and 90.9%, respectively. The overall adverse event rate was 4.9%, with no adverse events noted in cases with rigidizing overtubes. Conclusion: Despite the challenges in ERCP in patients with surgically altered anatomy, this retrospective analysis demonstrates a moderately high TS rate with minimal adverse events. A rigidizing overtube may be utilized to improve TS and CS in patients with post-surgical anatomy.
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Abstract : Background: Morbid obesity increases the risk of various diseases, including non-alcoholic fatty liver disease (NAFLD). Bariatric surgery is one of the most effective tools to achieve significant weight loss and reduce complications in morbidly obese people. The present study was conducted to assess the effects of bariatric surgery on NAFLD-related factors. Methods: This quasi-experimental study was conducted among 40 patients with obesity who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between July and November 2020. Biochemical factors and liver steatosis were evaluated by ultrasonography. Results: The results revealed a significant decrease in alanine aminotransferase, triglyceride, and low-density lipoprotein levels in both groups. After RYGB, a significant decline was observed in aspartate aminotransferase, alkaline phosphatase, and total cholesterol (TC) levels. In contrast, after SG, high-density lipoprotein levels were considerably elevated. Ultrasonography results showed a significant reduction in steatosis following RYGB, but not SG. However, no significant differences were observed between the two groups, except in TC levels. Conclusion: This study demonstrated that SG and RYGB had significant and beneficial short-term (6-month) effects on biochemical factors such as lipid profiles, liver enzymes, and blood glucose levels. While RYGB showed a slight advantage over SG in some parameters, the only statistically significant difference between groups was in the TC level. Furthermore, ultrasound findings revealed no statistically significant differences between SG and RYGB, suggesting that both procedures are effective at improving steatosis.
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Abstract : Background: Radiofrequency ablation (RFA) or microwave ablation (MWA) is effective for colorectal cancer liver metastases. We aimed to investigate the impact of different variables on survival. Methods: Sixty-four patients (142 lesions) who underwent thermoablation between January 2007 and January 2019 were retrospectively analyzed. The overall survival (OS) and liver progression-free survival (Li-PFS) were compared using Kaplan-Meier analysis. Univariable and multivariable Cox-regression were done to identify prognostic factors. Results: No significant difference was found between median OS (59.39 months) and Li-PFS (41.22 months) of patients who received MWA (n = 33); and median OS (61.00 months) and Li-PFS (53.43 months) of patients who received RFA (n = 31) (OS: P = 0.697; Li-PFS: P = 0.122). The median OS and Li-PFS were significantly decreased with lung metastases and K-ras mutations (P < 0.001). There was no correlation between prior systemic chemotherapy (n = 25) and both outcome parameters (OS: P = 0.613; Li-PFS: P = 0.665). No significant difference was observed in patients with lesions less than 30 mm diameter (n = 44) whether they received prior systemic chemotherapy (n = 17) or not (n = 27) (OS: P = 0.27; Li-PFS: P = 0.42). Similarly, in patients with a lesion of 3–5 cm diameter (n = 20; eight of them had prior chemotherapy), there was no correlation for both outcomes (OS: P = 0.069; Li-PFS: P = 0.71). The most important prognostic factor was concomitant lung metastases (hazard ratio = 3.689, P = 0.002). Conclusion: Concomitant lung metastasis and mutant K-ras were associated with shorter survival. Survival did not differ significantly regarding thermoablation technique or prior systemic chemotherapy. However, in the patient group with lung metastases, curative treatments had better survival than patients who received chemotherapy only. Additional therapeutic options should be considered in patients with concomitant lung metastasis.
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Abstract : Background: To evaluate and compare the efficacy of tissue ablation in electrocardiogram (ECG)-synchronized and non-synchronized irreversible electroporation (IRE) ablation using radiological and histological analyses. Methods: Five Yorkshire swine underwent 2,250 or 3,000 volt IRE ablation of multiple liver zones with high-rate, non-synchronized irreversible electroporation (nsIRE) pulses delivered at 240 pulses per minute (PPM) (n = 12) and ECG-synchronized irreversible electroporation (esIRE) pulses at either medium rate delivered at 50 PPM (n = 12) or low rate at 20 PPM (n = 6). We evaluated and compared the volume of ablation zones and IREinduced cell death between esIRE and nsIRE groups using radiological and histological analyses. Results: In ultrasound examination, no significant difference was observed between the size of esIRE and nsIRE treated areas in all three dimensions (P = 0.93, 240 PPM vs. 50 PPM and P = 0.89, 240 PPM vs. 20 PPM). The ablation areas were also well-correlated in gross pathological analysis, with no significant difference between esIRE and nsIRE groups (P = 0.55, 240 PPM vs. 50 PPM and P = 0.56, 240 PPM vs. 20 PPM). Gross and microscopic examinations demonstrated complete cell death in both esIRE and nsIRE cohorts with preservation of large blood vessels and bile ducts in both groups. No cardiac dysrhythmia was noted in esIRE group. Conclusion: In our study, no histological or radiological differences were observed between esIRE and nsIRE ablated areas. The esIRE ablation maintained its ability to create complete focal cell death.
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Abstract : Background: Intraoperative blood salvage and autotransfusion (IBS) is considered safe in liver transplantation for hepatocellular carcinoma (HCC). However, little is known about the potential impact of the viable tumor burden on recurrence and survival. This study investigated whether the presence of viable HCC during transplantation with IBS impacted HCC recurrence and patient survival. Methods: A retrospective study was conducted of liver transplants for patients with HCC in Atlantic Canada between 2005 and 2017. Information on locoregional treatment, IBS volume, and explant pathology was collected. Variables were analyzed to identify associations with HCC recurrence and patient survival via parametric and non-parametric tests. The Kaplan-Meier and log-rank tests were used to compare survival. Results: Sixty-eight subjects were included. IBS was used in 44.1% of the patients, with a median volume of 711 mL. Radiographic total tumor volume correlated well with the actual tumor viable volume (TVV) (Pearson’s r = 0.82, P < 0.01), but was overestimated by 50% when compared to the actual tumor burden on explant pathology. HCC recurrence was observed in 6 patients, and IBS was used in 5. Patients receiving IBS also had more viable tumors, but not a greater TVV. Overall patient survival did not exhibit significant differences according to the presence of viable tumors, vascular invasion, or satellitosis. Conclusion: IBS during liver transplantation was associated with significantly higher HCC recurrence in our limited series. However, the volume of viable HCC during the transplant procedure was not associated with any difference in tumor recurrence or patient survival.
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Abstract : Chronic pancreatitis (CP) is a chronic, progressive, inflammatory disease of the pancreas. Pancreatolithiasis is a complication of CP. In this case report, we present a patient with a giant solitary pancreatic stone that necessitated surgery. A 34-year-old patient with CP presented to our outpatient clinic with abdominal pain. Computed tomography revealed near-total atrophy of the pancreatic parenchyma and an 85-mm-long stone within the main pancreatic duct. Due to abdominal pain refractory to medical treatment and the long-term malignancy risk in the near-totally atrophic pancreas, the decision was made to perform surgery based on a multidisciplinary team meeting. Total pancreatectomy was carried out and a 30 × 85 mm pancreatic stone filling the main pancreatic duct was found in the specimen. Intractable pain, local complications of adjacent organs, and suspicion of a malignant lesion are indications for surgery in patients with CP. A case-based clinical approach is necessary for the management of pancreatic stones.
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Abstract : Plug-assisted retrograde transvenous obliteration has been recognized as a safe and effective treatment modality for patients with gastric variceal bleeding. The hallmark of this technique is to block the gastrorenal shunt (GRS) using an Amplatzer Vascular Plug, followed by infusion of gelatin sponge particles to completely occlude the varices. To ensure shunt occlusion and avoid device migration, the plug must be oversized by at least 20% compared to the shunt diameter. However, the maximal diameter of the commercially available plug is 22 mm, making the procedure technically infeasible for GRSs ≥ 18 mm. We report two challenging cases of recurrent gastric variceal bleeding due to liver cirrhosis and portal hypertension. Both patients had a giant and tortuous GRS with multiple dilated segments separated by waists. The transverse diameters of the GRSs were 24–30 mm and 23–32 mm, and the proximal waist diameters were 14 mm and 16 mm, respectively. Both GRSs were successfully embolized with 22-mm plugs. No bleeding recurrence was documented during 24 months.
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Abstract : Total regression without endoscopic treatment of colorectal adenoma is rare. We report the case of a 58-year-old male diagnosed with advanced gastric cancer and advanced colorectal adenoma. He received chemotherapy for gastric cancer and achieved regression of colorectal adenoma. To our knowledge, this is the first case of regression of colorectal adenoma.
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