Scandinavian Journal of Gastroenterology最新文献

Background and aims: This study evaluated the impact of monitoring with colonoscopy and magnetic resonance enterography on clinical decision-making and long-term outcomes in advanced therapy-naïve Crohn's disease patients with moderate-to-severe disease.

Methods: A retrospective review was conducted on 157 biologic-naïve Crohn's disease patients with moderate-to-severe disease at the initiation of advanced therapy between 2006 and 2023. Participants were categorized into three groups according to monitoring method within two years post-treatment: (1) tight monitoring (colonoscopy and magnetic resonance enterography), (2) semi-tight monitoring (either colonoscopy or magnetic resonance enterography), and (3) conventional monitoring (clinical outcomes including laboratory tests only). Treatment adjustments and long-term outcomes were compared.

Results: Of 157 patients (69.4% male, median age 31 years), tight monitoring was associated with increased immunomodulator use (27.2% vs. 3.8%; p < 0.001) and reduced hospitalizations compared to conventional monitoring (5.4% vs. 38.8%; p < 0.001). The incidence of strictures was 0% in the tight monitoring group, compared to 21.3% in the conventional monitoring group, respectively (p = 0.011).

Conclusion: Tight monitoring with both colonoscopy and magnetic resonance enterography within 2 years after advanced therapy initiation in patients with moderate-to-severe Crohn's disease is associated with timely treatment adjustments and improved long-term outcomes, particularly through better detection of residual inflammation.

Background and aims: Gallstone disease during pregnancy can have varying consequences, from mild to severe and even life-threatening. The aim was to investigate how gallstone intervention during pregnancy impacts pregnancy, delivery and the newborn child.

Methods: Pregnant patients 18-45 years identified from the Swedish National Register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) 2009-2016 constituted the intervention group and were cross-linked with the Swedish National Medical Birth Register. A 1:5 matched control group of patients without gallstone intervention during pregnancy was established.

Results: In total, 1620 women were included, and of these, 274 underwent gallstone intervention during pregnancy. Some 221 women underwent cholecystectomy only, and 53 underwent ERCP only or combined with cholecystectomy. The women in the intervention group had a higher BMI at the start of pregnancy (24 vs 28, p < .001) and were more often smokers (21.7% vs. 15.7%, p = .019). Overall, labour started most often spontaneously, (intervention group 67.0% vs. control group 75.3%, p = .004), and elective caesarean section was more common in the intervention group (13.2 vs. 9.0%, p = .034). Premature birth was more common in the intervention group (19 [6.93%] vs. 5 [3.94%], p = .029), with an adjusted odds ratio of 1.8 (CI 1.1-3.3, p < .001). There were no differences in the children's birth weights or APGAR scores.

Conclusions: Caesarean section was more common, and the duration of pregnancy was shorter, including preterm births, in the group with gallstone intervention during pregnancy. However, for the newborn child, birth weight corrected for gestational age and APGAR score was not affected.

Background: Acute pancreatitis is a potential life-threatening disease derived from different aetiologies. Knowledge about malpractice claims in acute pancreatitis is lacking. The aim of this study was to investigate the occurrence, patterns and outcomes of malpractice claims for management of acute pancreatitis.

Methods: Nationwide observational cohort of compensation claims filed in a single-payer, universal health care system with a national patient injury compensation system and reviewed by hospital specialists, primary care and health law.

Results: Some 40 claims were filed, among 24,715 episodes of acute pancreatitis. On average, 4.4 claims/year were filed, or 1 claim per every 727 episode of acute pancreatitis. Six claims were directed at primary healthcare (general practitioners (n = 4) and the emergency outpatient units (n = 2)), with none approved. Of all claims, 9 (22.5%) were approved, most frequent for biliary aetiology and related to errors or deviation in treatment (8/9). In 3 of the approved claims, death was the outcome of and part of the compensation approval (one under 'rule of exemption' for unexpectedly severe outcome). The adult population-adjusted claims-rate increased from 1.92 to 2.48/million inhabitants during the period. The claim-rate for events of acute pancreatitis increased from 1.48 to 1.58/1000 events of acute pancreatitis. A total indemnity compensation of 3.6 mill NOK (317 000 EUR) was paid.

Conclusion: Malpractice claims in acute pancreatitis are rare considering the number of episodes and variation in aetiology. Over 1 in 5 claims is granted compensation, most often related to treatment of biliary aetiology and for timing or indication of procedures.

Background: Double malignant biliary and duodenal obstruction is a frequent and debilitating complication of advanced biliopancreatic cancers. Endoscopic ultrasound (EUS)-guided biliary and enteric drainage techniques have emerged as alternatives to ERCP and duodenal stenting (DS), but optimal therapeutic sequencing remains unclear.

Patients and methods: We conducted a retrospective monocentric study including 34 patients treated for DMBO-DDO between February 2015 and December 2023. Inclusion required histologically confirmed tumors with both distal malignant biliary obstruction (DMBO) and high-grade gastric outlet obstruction (GOO). Treatment sequences were guided by the first symptom and validated by a multidisciplinary team. The primary endpoint was biliary reintervention rate according to different therapeutic combinations. Secondary endpoints included technical and clinical success, adverse events, and global reintervention rates.

Results: Mean patient age was 75 years, with pancreatic adenocarcinoma being the most common (58.8%). ERCP was the first procedure in 67.6% of cases. Technical success was 100% for all biliary interventions. The overall biliary reintervention rate was 52.9%, significantly higher in ERCP-based strategies (up to 77.8%) compared to EUS-guided approaches (18.2%-40%; p = 0.03). Lower initial bilirubin levels (<150 μmol/L) were also associated with increased reintervention rates (77.2% vs. 23.5%; p = 0.019). Complication rates were low (4.4% for grade ≥ III).

Conclusions: ERCP-first strategies for DMBO in the association of GOO showed significantly higher biliary reintervention rates compared to EUS-guided approaches. These findings suggest that EUS-based drainage should be favored in selected patients. Prospective multicenter studies are needed to refine treatment algorithms and confirm predictive factors for reintervention.

Background: Cytoreductive surgery (CRS) may benefit patients with metastatic gastrointestinal stromal tumors (GISTs) treated with tyrosine kinase inhibitors (TKIs). However, there is insufficient evidence on prognostic factors for metastatic GISTs undergoing CRS.

Methods: This study reviewed metastatic GISTs that underwent CRS after receiving TKIs in our center from April 2014 to December 2023. We collected clinicopathologic characteristics and survival data for analyses via the Cox hazard model and Kaplan-Meier method.

Results: Finally, 73 patients with metastatic GISTs who underwent CRS were enrolled. The TKI treatments used at time of surgery were imatinib (n = 53, 72.6%) and subsequent-line TKIs (n = 20, 27.4%). There were 30 patients (41.1%) with responsive disease (RD), 17 patients (23.3%) with unifocal progression disease (UP) and 26 patients (35.6%) with multifocal progression disease (MP) to TKIs at the time of surgery. The median follow-up time was 31 months. Multivariate Cox analysis revealed that MP (HR 2.406, p = 0.025), R2 resection (HR 2.532, p = 0.023), and mitotic index ≥5/50 HPFs (high-power fields) (HR 2.687, p = 0.022) independently predicted worse progression-free survival (PFS), and R2 resection predicted worse overall survival (OS) (HR 5.202, p = 0.039) for the entire cohort. In the subgroup analysis, radiographic response, extent of resection and mitotic index were prognostic factors for patients receiving imatinib but not those receiving subsequent-line TKIs. The rate of postoperative complications was 9.6% and the rate of grade III or higher complications was 4.1%.

Conclusions: Non-MP, R0/1 resection and mitotic index < 5/50 HPFs may predict better outcomes for patients with metastatic GISTs on imatinib, and CRS is feasible and safe.

Introduction: Endoscopic submucosal dissection (ESD) for colonic lesions frequently requires general anaesthesia (GA) or deep sedation to be performed. Saline-immersion/irrigation technique (SITE) improves tolerability as it reduces bowel distension and less stretching of the mesentery. We describe our experience with operator-delivered sedation (OdS) SITE-ESD on a cohort of colonic ESD.

Materials and methods: Retrospective single-centre study of consecutive anonymised patients who underwent SITE-ESD for colonic lesions from Nov-2017 to Feb-2025. Characteristics of patients and lesions, procedure outcomes and adverse events, details of sedation, and hospital admission were recorded.

Results: One-hundred-thirty-eight colonic lesions were included. Median age: 68 (IQR 62-76), ASA II was the most prevalent score (61.1%), the median maximum diameter of lesions was 40 mm (IQR 30-50), and the median resection time was 120 min (IQR 75-180). One-hundred-twenty-seven (127, 92.0%) procedures were performed under OdS with midazolam (median 6 mg; IQR 3.5-7.5) and fentanyl (137.5 mcg; IQR 100-200). No procedure was abandoned due to discomfort. Eighty-one (58.7%) procedures were day cases and of the remaining 57, 46 (80.7%) required less than 48 hrs admission. One case of moderate respiratory failure was recorded (AGREE II).

Discussion: SITE with OdS can be considered for colonic ESD.

Introduction: Self-reported non-coeliac gluten/wheat sensitivity (NCGWS) is triggered by gluten/wheat ingestion in patients without coeliac disease (CD) or wheat allergy. Following the COVID-19 pandemic, diagnoses of NCGWS appear to have declined. A gluten/wheat-free diet (GFD) remains the only management approach, though long-term adherence and outcomes are unclear. This study aimed to evaluate market trends and the long-term GFD adherence in NCGWS. Secondary objectives included evaluating perceived GFD efficacy and the need for further healthcare advice.

Methods: We analyzed UK market data on gluten-free (GF) product sales through September 2024 and shopper insights through July 2021. Additionally, patients with self-reported NCGWS diagnosed between 2006 and 2018 at a tertiary center completed a follow-up questionnaire about their dietary habits and further need of medical advice. GFD adherence was assessed using the Biagi score and compared with a matched cohort of CD patients.

Results: Market analysis showed a continued rise in GF product sales, from £214 m in 2014 to £607 m in 2024. NCGWS patients represented 9.7% of buyers. Of 186 patients, 111 completed the questionnaire. Compared to CD patients, those with NCGWS had significantly lower GFD adherence (Biagi score 0-1: NCGWS 73.9% vs. CD 8.1%; score 3-4: NCGWS 24.3% vs. CD 90.1%; p < 0.05). After discharge, 36% (n = 40) sought further medical advice, with no significant link between GFD adherence and need for intervention.

Conclusions: Although previous data suggests a drop in referrals to secondary care, up to 9.7% of our people are eating GF to treat self-reported NCGWS. The long-term GFD adherence is poor.

Backgrounds and aims: No guidelines exist for gastric acid assessment (GAA) or endoscopic surveillance for patients with Multiple Endocrine Neoplasia Type 1-Zollinger-Ellison Syndrome (MEN1-ZES). We aimed to analyze how GAA via nasogastric tube (NGT) and esophagogastro-duodenoscopy (EGD) altered acid suppression therapy and identify pre-GAA factors associated with post-GAA medication changes to inform which patients benefit from GAAs and/or EGDs for surveillance.

Methods: We assessed the following data from patients at our institution with MEN1-ZES from 2004-2018: 1) pre-GAA gastrointestinal symptoms; 2) serum gastrin levels; 3) gastric acid output (GAO); 4) EGD findings; 5) post-GAA changes in acid suppressing medication. GAO of <10 milliequivalents (mEq) of hydrochloric acid per hour (hr) indicated adequate acid suppression.

Results: Fifty-one patients who underwent 313 EGD/GAAs were identified; 263 EGD/GAAs were included. 51/263 EGD/GAAs (19.4%) led to increased acid suppression medication. Of these, 47.1% had GAO > 10 mEq/hr. Patients who had increases in acid suppression medication had significantly more symptoms, abnormal endoscopic findings, and higher GAOs compared to patients treated with same or decreased dose after endoscopy. All patients without symptoms prior to EGD/GAA were adequately suppressed. 8 NGT/GAAs done in 6 asymptomatic patients demonstrated adequate suppression.

Conclusion: GAA is inadequately sensitive for detecting which patients with MEN1-ZES will benefit from increased acid suppression medication. Patients with symptoms should undergo EGD. A majority of patients without symptoms will not require increased acid suppressing medication following GAA, but a few asymptomatic patients may have endoscopic findings warranting increased therapy. There is no clear clinical benefit for NGT/GAA in asymptomatic patients.

Objectives: Hepatocellular carcinoma (HCC) is a significant global health burden. Examining treatment sequencing before the introduction of immune-based therapies is important for understanding the role and necessity of modern treatment approaches.

Material and methods: This retrospective study analysed 1020 patients with HCC treated at Karolinska University Hospital, Stockholm, between 2010 and 2017 to explore treatment sequencing, and clinical outcomes. Treatment decisions followed a modified Barcelona Clinic Liver Cancer (BCLC) algorithm, and patients were stratified by disease stage and by type of treatment.

Results: Initial treatment strategies included best supportive care (BSC, 32%), ablation (20%), transarterial chemoembolization (TACE, 22%), systemic therapy (12%), resection (12%), and liver transplantation (3%). Median survival ranged from 4.8 years in BCLC 0 to 2.3 months in BCLC D. Curative treatments, particularly liver transplantation, achieved the highest five-year survival (82%), whereas systemic therapy and BSC had the poorest five-year survival (2% and 0%). Despite curative intent, disease recurrence was common, necessitating further treatment in most patients. Treatment sequencing revealed that 37% of patients required a second treatment, and 18% progressed to a third line of therapy.

Conclusions: This study underscores the challenges of managing HCC in a real-world setting, including late diagnosis and high recurrence rates following curative treatments. Real-world treatment deviations from guidelines were observed, often influenced by patient comorbidities, performance status, or other clinical considerations.