Journal of Gastroenterology and Hepatology最新文献

Background: Barrett's esophagus is the known precursor to esophageal adenocarcinoma (EAC), a cancer with poor prognosis. While endoscopic surveillance detects early dysplasia and prevents progression, most Barrett's esophagus patients do not progress to EAC, leading to invasive and costly surveillance. This study aimed to identify cost-effective endoscopic surveillance strategies by risk stratifying patients based on Barrett's esophagus segment length and sex.

Methods: A Markov cohort model was developed to simulate the natural history of Barrett's esophagus to EAC. The model assessed 85 surveillance strategies and varied endoscopy intervals from 2 to 10 years for nondysplastic Barrett's esophagus and 6-12 months for dysplasia. Risk stratification was based on segment length (≤ 2 and ≤ 3 cm) and sex. Costs, utilities and transition probabilities were derived from published literature and clinical databases. Deterministic and probabilistic sensitivity analyses were performed, and cost-effectiveness was evaluated from a third-party payer perspective using a threshold of AU$50 000/QALY (2023 US dollars 35 945/QALY).

Results: The most cost-effective strategy was biennial surveillance for long-segment BE (> 2 cm) and 12-month surveillance for LGD, excluding surveillance in low-risk patients (ICER US$23 737/QALY). Risk-based surveillance consistently outperformed nonstratified strategies. Sensitivity analyses confirmed the robustness of the model, with key drivers being transition rates and endoscopy costs.

Conclusion: We identified cost-effective risk-stratified endoscopic surveillance strategies for Barrett's esophagus, particularly when excluding low-risk patients. Tailored risk-guided surveillance strategies could improve resource allocation and clinical outcomes in managing Barrett's esophagus. The conserved resources can then be utilized to identify high-risk individuals in the community.

Background: Endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a popular alternative for patients in whom performing endoscopic retrograde cholangiopancreatography (ERCP) is difficult; however, EUS-BD for malignant hilar biliary obstruction (MHBO) remains controversial, particularly for bilateral drainage. This study aimed to examine the efficacy of EUS-guided bilateral stent-in-stent deployment (EUS-SIS) in patients with unresectable MHBO.

Methods: This retrospective study investigated consecutive patients with MHBO in whom ERCP was difficult or failed and EUS-SIS was attempted. A total of 20 patients met the inclusion criteria. Study outcomes included technical and clinical success, recurrent biliary obstruction (RBO), and other adverse events associated with EUS-SIS.

Results: The technical success rate of EUS-SIS was 75% (15/20). The main reason for the technical failure was the inability to advance the guidewire into the contralateral intrahepatic bile duct. Clinical success was achieved in all technically successful cases. The early and late adverse event rates were 5% (1/20) and 7% (1/15), respectively. The incidence rate of RBO was 33% (5/15), and reintervention for RBO via the EUS-BD route was successful in all cases. The median time to RBO was 161 days, and the median overall survival was 191 days.

Conclusions: EUS-SIS was promising for performing bilateral drainage when ERCP failed in patients with MHBO. However, to establish this technique as a widely accepted treatment, its technical success rate needs to be improved.

Background: Early esophageal cancer is prone to lymphovascular invasion (LVI) and ductal involvement (DI), which seriously affects the prognosis of patients. Therefore, identifying the potential risk factors for LVI/DI is crucial. This study aims to clarify endoscopic appearances which are predictive for LVI/DI in patients with node-negative superficial esophageal squamous cell carcinoma (SESCC).

Methods: A total of 401 lesions were included for model development. Endoscopic image features were selected through multivariate logistic regression and LASSO (least absolute shrinkage and selection operator) regression analysis, and the optimal model was determined by calculating cNRI (continuous net reclassification improvement) and IDI (integrated discrimination improvement). Additionally, internal and external validation were performed using data from 173 and 133 lesions, respectively.

Results: Five endoscopic image features, including lesion length, macroscopic type, surface granularity, surface nodularity, and surface erosion, were identified as predictive factors and were incorporated into the nomogram. The nomogram demonstrated substantial predictive efficacy, as evidenced by the AUC (area under curve) values of 0.854 (95% CI: 0.809-0.899) for the training set, 0.821 (95% CI: 0.749-0.894) for the internal validation set, and 0.860 (95% CI: 0.765-0.955) for the external validation set. Calibration curves showed good agreement between the nomogram predictions and actual observations. DCA (decision curve analysis) and CICs (clinical impact curves) confirmed the nomogram's clinical applicability.

Conclusions: We constructed a nomogram based on preoperative endoscopic image features for predicting the risks of LVI/DI in patients with node-negative SESCC, which may aid in clinical decision-making.