United European Gastroenterology Journal最新文献

Background and aim: Direct cholangioscopy and pancreatoscopy have become widely implemented techniques in the diagnostic and therapeutic algorithms of several pancreaticobiliary disorders. This study aimed to generate general and indication-specific European consensus recommendations on cholangioscopy and pancreatoscopy.

Methods: Supported by the available literature, statements were formulated and grouped into the following categories: (1) pre-procedural considerations, (2) general technical aspects, (3) biliopancreatic stones, (4) biliary strictures, and (5) other indications. The evidence level of each statement was determined using the GRADE methodology. Cholangioscopy experts were invited to participate in a modified Delphi process. When 80% consensus was not reached, the statement was modified based on expert feedback and subjected to an additional Delphi round. Statements were rejected if they failed to reach consensus after three Delphi rounds.

Results: Thirty cholangioscopy experts completed the Delphi process. Forty-two (97.6%) generated statements were accepted, of which 39 (92.9%) in the first Delphi round. 12 statements on preprocedural and periprocedural settings, 8 statements on biliopancreatic stones, 13 statements on biliary strictures, and 9 statements on other indications were accepted.

Conclusion: Using a modified Delphi process, we developed general and indication-specific consensus recommendations for cholangioscopy to guide clinical practice.

Background: Remimazolam is a short-acting benzodiazepine with less cardiorespiratory depression compared with propofol. The Oxygen Reserve Index (ORi) reflects oxygenation status in the mild hyperoxic range and can detect subtle respiratory depression induced by sedatives.

Objective: We compared remimazolam and propofol in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and assessed the ORi to evaluate the impact of these sedatives on oxygen reserve.

Methods: Patients scheduled for ERCP were enrolled and randomly assigned to either the remimazolam or the propofol group. They received 0.1 mg kg^-1 remimazolam or 1.0 mg kg^-1 propofol, with bolus injections of either 2 mg remimazolam or 20 mg propofol added as required, according to the group allocation. The primary outcome was the incidence of oxygen reserve depletion, defined as an ORi reduction to 0.00.

Results: Among the 102 patients, oxygen reserve depletion was more frequent in the propofol group (70.6% vs. 41.2%, odds ratio 0.29, 95% confidence interval 0.13-0.66, p = 0.003). The time from sedative injection to endoscope insertion, length of stay in the recovery room, and overall procedure time were comparable between the groups. Patients in the remimazolam group reported a lower incidence of procedural recall, fewer complaints of inadequate sedation, and higher satisfaction scores than those in the propofol group.

Conclusions: Remimazolam effectively preserved the oxygen reserve compared with propofol, lowering the risk of hypoxia during sedation. Remimazolam was also associated with more favorable recovery profiles for patients undergoing ERCP, making it a safe and preferred sedative for this procedure.

Trail registration: Clinicaltrials.gov: NCT06359834.

Pancreatic ductal adenocarcinoma (PDAC) remains one of the most lethal malignancies, mainly due to its aggressive nature, early metastasis, diagnosis at late stages, and limited response to systemic anticancer therapy. Perineural invasion (PNI), defined as the infiltration of neoplastic cells along nerve fibers and within nerve sheaths, is emerging as a critical determinant of PDAC aggressiveness. This position paper by the TRANSPAN PNI Group on Perineural Invasion synthesizes current evidence on the molecular features and clinical implications of PNI in PDAC, compares its prognostic significance in other malignancies, and describes novel biomarker strategies including potential therapeutic interventions.

Background: Biliary acute pancreatitis (AP) during pregnancy is a challenging situation, and current guidelines for AP, pregnancy care, and surgery do not specifically address its management. This study investigated the safety and effectiveness of cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy in AP.

Methods: This international retrospective multicenter cohort study encompassed questions related to demographic information, clinical presentation, management strategies, timing of cholecystectomy, approaches to the procedure, complications, and outcomes. Continuous variables were summarized as medians with interquartile ranges, and categorical variables as frequencies and percentages. Group comparisons used Welch's t-test, Pearson's chi-squared, or Fisher's exact tests.

Results: A total of 101 cases from 14 countries and 19 centers were enrolled. Cholecystectomy after mild AP during pregnancy had a lower rate of readmission due to recurrent AP or other gallstone-related complications compared with those who did not undergo surgery after a mild AP during pregnancy (0% vs. 24%; n = 0/17 vs. n = 12/49, p = 0.027). Cholecystectomy performed during pregnancy was associated with a low surgical complication rate, identical to that seen in postpartum procedures (12% vs. 10%; n = 2/17 vs. n = 3/30; p > 0.999). Preterm birth occurred in 7.1% (n = 1/14) of patients with cholecystectomy versus 11% (n = 5/45) without. Fetal loss after surgery occurred only in the first trimester (n = 3/17 vs. n = 1/49). No difference was seen in readmission (5%, n = 1/21 vs. 27%, n = 4/15; p = 0.138), fetal loss (5%, n = 1/21 vs. 27%, n = 4/15; p = 0.138) and preterm birth (6%, n = 1/17 vs. 8%, n = 1/12; p > 0.999) between the surgical and ERCP groups. The fetal loss (9.1%, n = 2/22 vs. 5.4%, n = 4/74; p = 0.618) and preterm birth rates (5.9%, n = 1/17 vs. 12%, n = 8/65; p = 0.677) did not significantly differ between patients with and without ERCP during pregnancy.

Conclusion: Cholecystectomy is effective and safe in pregnant patients during the second or third trimester in cases of mild biliary pancreatitis. ERCP is safe in any trimester.

Background: Early advanced inflammatory bowel disease (IBD) therapy is emphasised to prevent disease progression and restore quality of life.

Aims: To evaluate the potential advantages of early versus late anti-tumour necrosis factor (TNF) therapy in patients with IBD.

Methods: This retrospective study included patients with newly diagnosed IBD (2004-2018) who received anti-TNF therapy and had at least 1 year of follow-up. Patients were categorised as early or late users based on a 2-year post-diagnosis cut-off for first anti-TNF exposure. Outcomes included IBD-related surgeries, hospitalizations, emergency department (ED) visits, and drug persistence. Subgroup analysis examined concurrent immunomodulator use, and sensitivity analyses were employed 6 months or 1 year post-diagnosis cut-offs.

Results: Among 8105 patients with ulcerative colitis (UC) and 8465 with Crohn's disease (CD), distinct outcomes emerged. Early anti-TNF users with UC had significantly higher hospitalization (hazard ratio [HR] 1.34, 95% confidence interval [CI] 0.91-1.96) and ED visit rates (HR 1.30, 95% CI 1.16-1.46) compared with late users. In CD, early users showed a non-significant trend toward fewer event rates. Drug persistence was longer among late users for both UC and CD. In UC, combining immunomodulators with early anti-TNF increased hospitalization and ED visits but not in CD. Sensitivity analyses confirmed the primary findings.

Conclusions: While early anti-TNF use was associated with differential outcomes in CD, the relationship between treatment timing and clinical course diverged in UC, challenging the assumption that early intervention is universally advantageous across IBD subtypes. These findings underscore the need for further research to identify patient subgroups that might benefit most from early intervention.

Background: Chronic pancreatitis is a risk factor for pancreatic cancer. Autoimmune pancreatitis is a unique form of chronic pancreatitis that is primarily characterized by its immune mediate etiology, clinically resembling pancreatic cancer, yet uniquely responsive to steroid treatment.

Objective: Early and accurate diagnosis of autoimmune pancreatitis is vital for effective treatment and patient prognosis, for which new diagnostic tools are urgently required. Gut microbiota dysbiosis has been identified to correlate with the development of pancreatic diseases, which provides new opportunities for the discovery of disease biomarkers.

Methods: We utilized a mass spectrometric global metabolomics investigation of patient autoimmune pancreatitis and chronic pancreatitis fecal samples, investigating microbiome, dietary and human metabolism.

Results: We discovered a series of newly identified metabolic signatures between both patient groups including enterolactone, 4-guanidinobutanoic acid, and methylthioadenosine sulfoxide. Additionally, the analysis revealed significant differences in several metabolic pathways such as fatty acids, alkaloids, amino acids and peptides.

Conclusion: Our observations provide novel insights into important metabolic human pathways and microbiome-derived metabolites to distinguish autoimmune pancreatitis from chronic pancreatitis. These findings reveal systemic metabolic responses and the identified metabolites may be developed into potential biomarkers for future diagnosis to distinguish between autoimmune pancreatitis and chronic pancreatitis.