Annals of Gastroenterology最新文献

Digestive tract carcinomas are the most commonly occurring cancers worldwide, but their prognosis with traditional treatments remains poor. T lymphocytes are well-recognized as crucial components of effective anti-tumor immunity, and current immunotherapeutic strategies concentrate mainly on T-cell-mediated immunity reinforcement, whereas the role of B lymphocytes and plasma cells (PCs) has been neglected in the past, and it is only recently that these cells have been considered as key players in the tumor microenvironment (TME). In this review, we describe the complex dual role of B lymphocytes and PCs in promoting and inhibiting tumor progression in the TME of digestive tract carcinomas, and we demonstrate their prognostic value. Furthermore, we highlight their controversial function in cancer and nominate them as additional therapeutic targets for the development of new treatment interventions that might alter the dismal prognosis of digestive tract tumors.

Background: Immune checkpoint inhibitors (ICI) target microsatellite instability-high (MSI-H) tumors with success. The incidence and characteristics of ICI-related colitis (IMC) in patients with MSI-H colorectal cancers (CRC) are unclear.

Methods: We performed a retrospective analysis of adult patients with CRC who received ICI between June 1, 2014, and December 31, 2022, including data on IMC observed up to 3 months after the last dose of ICI. Patients' demographics, oncologic profile, endoscopic features, treatment and clinical outcomes were evaluated.

Results: Of 474 patients with CRC receiving ICI during our study period, 18 developed IMC (3.8%). The majority were Caucasian (88.8%), male (61.1%), and their median age was 69.5 years. Of these patients, 50% received combination therapy with anti-PD-1/L1 and CTLA-4; 66.6% had MSI-H colorectal cancer, 11.1% had a second cancer-melanoma, while 61.2% and 66.7% had grade 1-2 colitis and diarrhea respectively. Endoscopic evaluation was used in 5 patients, of whom 2 had ulcerative inflammation necessitating selective immunosuppressive therapy with biologics. Therapy was withheld in 61.1% because of toxicity; 41.4% and 5.8% were noted to have median Common Terminology Criteria for Adverse Events grade 2 liver and pancreas toxicity respectively. The majority of our cohort received steroid therapy.

Conclusions: The lower severity of IMC, compared to toxicity in other ICI-treated cancers, may be influenced by the tumor microenvironment in MSI-H colorectal cancer after ICI exposure. Larger prospective studies are necessary to determine the role of tumor biology and the gut microbiome in the disease profile and severity of IMC.

Background: The current allocation system for liver transplantation (LT) is based on the sickest-first policy, using objective variables to ensure equal priority. However, under-prioritization of female patients for LT, compared to males, is well demonstrated and new scores have been proposed to overcome this systematic bias. This study evaluated the ability of these new scores to predict the long-term outcomes of patients with cirrhosis.

Methods: The clinical and laboratory characteristics of 694 consecutive candidates for liver transplantation from 2 liver transplant centers were recorded. The model for end-stage liver disease (MELD)-based scores (MELD, MELD-Sodium and MELD 3.0), as well as the Gender-Equity Model for liver Allocation (GEMA) and GEMA-Sodium, were used to assess the severity of liver disease. Patients were followed-up prospectively and their outcomes assessed.

Results: During a follow-up period of median length 12 months (range: 4-52), 28.5% of patients died, 21% of patients underwent LT, while 50.5% remained alive. Female patients had significantly lower MELD and MELD-Sodium scores compared to males, attributable to their significantly lower creatinine, while MELD 3.0, GEMA and GEMA-Sodium did not differ between the 2 sexes. In multivariate Cox regression analysis, GEMA-Sodium was the only factor independently associated with death/LT, and showed very good discriminative ability (hazard ratio 1.10, 95% confidence interval 1.073-1.128; P<0.001). These findings were confirmed in several subgroup analyses.

Conclusions: Our findings show for the first time the predictive ability of GEMA-Sodium for the long-term outcomes of LT candidates. However, further studies are needed to confirm these findings.

Background: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a common surgical procedure for ulcerative colitis and familial adenomatous polyposis. IPAA strictures are a known complication, often requiring surgical intervention. Endoscopic interventions offer a less invasive alternative, but their safety and efficacy remain uncertain.

Methods: A comprehensive literature search was performed to identify pertinent studies. Outcomes assessed were technical success, clinical success (immediate and end of follow up), pouch failure rate and adverse events. Pooled estimates were calculated using random effects models with a 95% confidence interval.

Results: A total of 607 patients from 9 studies were included. Technical success, defined as the ability to pass the endoscope through the stricture, was achieved in 97.4% of patients. Immediate clinical success, defined as symptom improvement post-intervention, was seen in 44.5% of patients. Clinical success at the end of follow up was observed in 81.7% of patients. However, 6.8% of patients experienced pouch failure and ultimately 14.5% required surgical intervention for refractory strictures or complications. Endoscopic intervention-related serious adverse events occurred in 3.9% of patients, including perforation and major post-procedural bleeding.

Conclusions: Endoscopic interventions for IPAA strictures demonstrate high technical success rates, providing a less invasive option for managing this complication. While clinical success rates immediately post-procedure and at end of follow up are promising, a significant proportion of patients ultimately require surgical intervention for pouch failure or refractory strictures.

Background: Helicobacter pylori (H. pylori) infection is associated with various gastrointestinal diseases and may lead to gastric cancer. Currently, endoscopy is the gold standard modality used for diagnosing H. pylori infection, but it lacks objective indicators and requires expert interpretation. In the past few years, the use of artificial intelligence (AI) for diagnosing gastrointestinal pathologies has increased tremendously and may improve the diagnostic accuracy of endoscopy for H. pylori infection. This study aimed to evaluate the diagnostic accuracy of AI algorithms for detecting H. pylori infection using endoscopic images.

Methods: Three investigators searched the PubMed, CINHAL and Cochrane databases for studies that compared AI algorithms with endoscopic histopathology for diagnosing H. pylori infection using endoscopic images. We assessed the methodological quality of studies using the QUADAS-2 tool and performed a meta-analysis to estimate the pooled sensitivity, specificity, and accuracy of AI for detecting H. pylori infection.

Results: A total of 11 studies were identified that met our inclusion criteria. All were conducted in different countries based in Asia. Our meta-analysis showed that AI had high sensitivity (0.93, 95% confidence interval [CI] 0.90-0.95), specificity (0.92, 95%CI 0.89-0.94), and accuracy (0.92, 95%CI 0.90-0.94) for detecting H. pylori infection using endoscopic images. However, there was also high heterogeneity among the studies (Tau²=0.87, I ²=76.10% for generalized effect size; Tau²=1.53, I ²=80.72% for sensitivity; Tau²=0.57, I ²=70.86% for specificity).

Conclusion: This systematic review and meta-analysis showed that AI had high diagnostic accuracy for detecting H. pylori infection using endoscopic images.

Background: The pattern of hepatocellular carcinoma (HCC) recurrence after resection/ablation is intrahepatic and/or systemic. The efficacy of atezolizumab-bevacizumab treatment as early therapy after recurrence has not been extensively evaluated.

Methods: We evaluated 32 patients (group A) with early HCC recurrence after resection/ablation and 24 patients (group B) initially diagnosed as Barcelona Clinic Liver Cancer (BCLC)-C, all treated with atezolizumab-bevacizumab. Group A was subdivided in group A1 (progression to BCLC-C, n=14) and group A2 (progression to BCLC-B, n=18).

Results: Groups A1/A2 were comparable for all baseline parameters. Objective response was observed in 14.3% and 33.3% of patients in groups A1 and A2, respectively. Median overall survival (OS) was impressive and comparable between the 2 groups (22 and 26 months, respectively, P=0.71), as was median progression-free survival (PFS) (15 and 6 months, respectively, P=0.126). Patients categorized in the advanced stage (groups A1/B) were comparable for all baseline characteristics. Median OS was significantly higher in group A1 compared to B (26 vs. 6 months, P<0.001), as was median PFS (6 vs. 3 months, P=0.086).

Conclusions: Early initiation of atezolizumab-bevacizumab after recurrence following curative therapy results in impressive survival rates, irrespective of recurrence pattern. Survival of atezolizumab-bevacizumab treated patients who were initially diagnosed in the BCLC-C stage is significantly different from those who recurred to BCLC-C following potentially curative therapies.

Background: With the increasing complexity and prolonged duration of endoscopic retrograde cholangiopancreatography (ERCP) procedures, sedation shifted from conscious sedation with benzodiazepines to deep sedation with propofol. We assessed the technical success and adverse event rates of ERCP with deep versus conscious sedation.

Methods: Consecutive patients treated with ERCP in the University Medical Center Utrecht over a 7-year period (2010-2016) were screened for eligibility. Gastroenterologist-administered conscious sedation with midazolam was used from 2010-2013, whilst anesthesiology-administered deep sedation with propofol was used from 2013-2016. Data were retrospectively collected from electronic medical records. Outcomes were technical success and procedure-related adverse events within 30 days after ERCP. Associations of sedation type with outcomes were analyzed in univariable and multivariable analyses.

Results: A total of 725 patients were included: 336 (46%) with conscious sedation and 389 (54%) with deep sedation. Technical success was significantly higher when propofol-based sedation was used (317 [82%] vs. 252 [75%], P=0.034). Adverse events also occurred significantly more often in the propofol group (77 [20%] vs. 38 [11%], P=0.002), due to higher rates of post-ERCP cholangitis (21 [5%] vs. 8 [2%], P=0.039), and post-ERCP pancreatitis (29 [7%] vs. 11 [3%], P=0.014). After adjustment, propofol-based sedation remained significantly associated with technical success and adverse events, with odds ratios of 1.53 (95% confidence interval [CI] 1.05-2.21) and 1.95 (95% CI 1.25-3.04), respectively.

Conclusion: Propofol-based sedation resulted significantly more often in technical success of ERCP compared with midazolam-based sedation, but adverse events were almost twice as common, with higher rates of post-ERCP pancreatitis and cholangitis.

Background: Pancreatic cancer is a neoplastic condition with a high disease burden. It is projected to be the second most common cause of cancer-related deaths by 2030. However, evidence supporting the long-term use of aspirin in cancer prevention and treatment remains insufficient. We aimed to investigate the association between aspirin use and pancreatic cancer outcomes in the elderly population group.

Methods: The 2020 National Inpatient Sample was used to investigate records of elderly patients admitted with pancreatic cancer, identified by ICD-10 CM codes. The data were categorized based on long-term aspirin use. We assessed inpatient mortality as the primary outcome, while secondary outcomes included costs and length of stay, as well as other inpatient complications.

Results: We identified 19,249 hospitalizations of patients aged over 60 years. The mean age was 73.8 years, and 49.3% were male. In a survey multivariate logistic and linear regression model, adjusting for patient characteristics and hospital factors, long-term aspirin use was associated with lower inpatient mortality (adjusted odds ratio [aOR] 0.55, 95% confidence interval [CI] 0.33-0.92; P=0.023), a shorter hospital stay (beta coefficient -0.52, 95%CI -0.93 to -0.11; P=0.012), lower odds of acute kidney injury (aOR 0.76, 95%CI 0.59-0.98; P=0.039), and lower odds of shock (aOR 0.23, 95%CI 0.06-0.78; P=0.019]. Post-propensity matching revealed similar patterns.

Conclusions: Long-term aspirin use is associated with a lower rate of inpatient mortality and other clinical outcomes in hospitalized elderly patients with pancreatic cancer. The etiologies behind this relationship should be explored with a view to better understanding.

Background: Currently, laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM) are the best treatment modalities for esophageal achalasia in children. The purpose of this systematic review and meta-analysis is to compare the efficacy of LHM and POEM.

Methods: A systematic literature search was performed in PubMed/Medline, Google Scholar and Web of Science for original articles comparing LHM and POEM. All articles were analyzed with respect to operation duration, length of hospital stay, pre- and postoperative Eckardt score (ES), and pre- and postoperative lower esophageal sphincter (LES) pressure.

Results: A total of 32 articles, reporting on 800 children, were selected and reviewed. Because of missing diagnostic values of ES and LES in the LHM group, the meta-analysis was limited to the POEM results. According to the random-effects model, the mean ES difference between pre- and post-operation was 4.387 (95% confidence interval [CI] 3.799-4.974), significantly different to zero (z=14.64, P<0.001), while the mean LES pressure difference was 3.63 mmHg mmHg (95%CI 2247-3.879), significantly different to zero (z=7.36, P<0.001). Operation duration was 130.15 min (95%CI 62.59-197.71) for the LHM method and 83.64 min (95%CI 55.14-112.14) for POEM. The pooled estimate of length of hospital stay was 3.4 days (95%CI 2.6-4.44) and it was comparable between the 2 methods.

Conclusions: POEM has positive outcomes regarding ES and LES pressure pre- and postoperatively, as well as operation duration, while the length of hospitalization was comparable between POEM and LHM. Well-designed studies are warranted to further clarify differences between the 2 methods.