Publications by authors named "Marco Bruno"

325 Publications

Long-term yield of pancreatic cancer surveillance in high-risk individuals.

Gut 2021 Apr 5. Epub 2021 Apr 5.

Department of Gastroenterology & Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.

Objective: We aimed to determine the long-term yield of pancreatic cancer surveillance in hereditary predisposed high-risk individuals.

Design: From 2006 to 2019, we prospectively enrolled asymptomatic individuals with an estimated 10% or greater lifetime risk of pancreatic ductal adenocarcinoma (PDAC) after obligatory evaluation by a clinical geneticist and genetic testing, and subjected them to annual surveillance with both endoscopic ultrasonography (EUS) and MRI/cholangiopancreatography (MRI/MRCP) at each visit.

Results: 366 individuals (201 mutation-negative familial pancreatic cancer (FPC) kindreds and 165 PDAC susceptibility gene mutation carriers; mean age 54 years, SD 9.9) were followed for 63 months on average (SD 43.2). Ten individuals developed PDAC, of which four presented with a symptomatic interval carcinoma and six underwent resection. The cumulative PDAC incidence was 9.3% in the mutation carriers and 0% in the FPC kindreds (p<0.001). Median PDAC survival was 18 months (range 1-32). Surgery was performed in 17 individuals (4.6%), whose pathology revealed 6 PDACs (3 T1N0M0), 7 low-grade precursor lesions, 2 neuroendocrine tumours <2 cm, 1 autoimmune pancreatitis and in 1 individual no abnormality. There was no surgery-related mortality. EUS detected more solid lesions than MRI/MRCP (100% vs 22%, p<0.001), but less cystic lesions (42% vs 83%, p<0.001).

Conclusion: The diagnostic yield of PDAC was substantial in established high-risk mutation carriers, but non-existent in the mutation-negative proven FPC kindreds. Nevertheless, timely identification of resectable lesions proved challenging despite the concurrent use of two imaging modalities, with EUS outperforming MRI/MRCP. Overall, surveillance by imaging yields suboptimal results with a clear need for more sensitive diagnostic markers, including biomarkers.
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http://dx.doi.org/10.1136/gutjnl-2020-323611DOI Listing
April 2021

Influence of a novel classification of the papilla of Vater on the outcome of needle-knife fistulotomy for biliary cannulation.

BMC Gastroenterol 2021 Apr 1;21(1):147. Epub 2021 Apr 1.

Cintesis - Center for Health Technology and Services Research, Porto, Portugal.

Background: Existing proposed classification systems for the Papilla of Vater (PV) suboptimally account for all relevant, encountered PV appearances, are too complex or have not been assessed for intra- or interobserver variability. We proposed a novel endoscopic classification system for PV, determined its inter- and intraobserver rates and used the classification system to assess whether the success and complications of needle-knife fistulotomy (NKF) are influenced by the morphology of the PV.

Methods: The classification system was developed by expert endoscopists. To evaluate the inter- and intraobserver agreement, an online questionnaire was sent to 20 endoscopists from several countries (10 experts and 10 nonexperts) that included 50 images of papillae of Vater divided among various categories. Four weeks later, a second survey, with the images from the first questionnaire randomly reordered, was sent to the same endoscopists. The inter- and intraobserver agreements among the experts and nonexperts was calculated. Using the proposed classification system, all 361 consecutive patients who underwent NKF for biliary access to a naïve papilla were prospectively enrolled in the study.

Results: The novel classification system comprises 7 categories: type I, flat type, lacking an oral protrusion; type IIA, prominent tubular nonpleated type, with an oral protrusion and < 1 transverse fold over the oral protrusion; type IIB, prominent tubular pleated type, with an oral protrusion and > 2 transverse folds over the oral protrusion; type IIC: prominent bulging type, with an enlarged and bulging oral protrusion; type IIIA, diverticular-intradiverticular type, with a papillary orifice inside the diverticulum; type IIIB: diverticular-diverticular border type, with a papillary orifice less than 2 cm from the diverticular border; type IV: unclassified papilla, with no morphology classified in the other categories. The interobserver agreement between experts was substantial (K = 0.611, 95% CI 0.498-0.709) and was higher than that between nonexperts (K = 0.516; 95% CI 0.410-0.636). The intraobserver agreement was substantial among both experts (K = 0,651; 95% CI 0.586-0.715) and nonexperts (K = 0.646, 95% CI 0.615-0.677). In a multivariate model, type IIIA and IIIB were the only independent risk factors for difficult rescue NKF biliary cannulation (P = 0.003 and P = 0.019, respectively), and type I and type IIB were the only independent risk factors for a prolonged cannulation time using NKF (P < 0.001 and P = 0.005, respectively).

Conclusions: The novel endoscopic classification system for PV is highly reproducible among experienced ERCPists according to the substantial level of agreement between experts. However, nonexperts require further training in its use. Using the novel classification system, we identified different types of papillae significantly associated with a lower efficacy of NKF and a prolonged time to obtain successful biliary cannulation using NKF.
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http://dx.doi.org/10.1186/s12876-021-01735-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8017832PMC
April 2021

Fully Covered Self-Expanding Metal Stent versus Multiple Plastic Stents to Treat Benign Biliary Strictures Secondary to Chronic Pancreatitis: A Multicenter Randomized Trial.

Gastroenterology 2021 Mar 16. Epub 2021 Mar 16.

Asian Institute of Gastroenterology, Hyderabad, India. Electronic address:

Background & Aims: Benign biliary strictures (BBS) are complications of chronic pancreatitis (CP). Endotherapy using multiple plastic stents (MPS) or a fully covered self-expanding metal stent (FCSEMS) are acceptable treatment options for biliary obstructive symptoms in these patients.

Methods: Patients with symptomatic CP-associated BBS enrolled in a multicenter randomized noninferiority trial comparing 12-month treatment with MPS versus FCSEMS. Primary outcome was stricture resolution status at 24 months, defined as absence of restenting and 24-month serum alkaline phosphatase not exceeding twice the level at stenting completion. Secondary outcomes included crossover rate, numbers of ERCPs and stents, and stent- or procedure-related serious adverse events (SAEs).

Results: Eighty-four patients were randomized to MPS and 80 to FCSEMS. Baseline technical success was 97.6% for MPS and 98.6% for FCSEMS. Eleven patients crossed over from MPS to FCSEMS, and 10 from FCSEMS to MPS. For MPS vs. FCSEMS respectively, stricture resolution status at 24 months was 77.1% (54/70) vs. 75.8% (47/62) (P=0.008 for noninferiority ITT analysis), mean number of ERCPs was 3.9±1.3 vs. 2.6±1.3 (P<0.001, ITT), and mean number of stents placed was 7.0±4.4 vs. 1.3±0.6 (P<0.001, as-treated). SAEs occurred in 16 (19.0%) MPS and 19 (23.8%) FCSEMS patients (P=0.568), including cholangitis/fever/jaundice (9 vs. 7 patients respectively), abdominal pain (5 vs. 5), cholecystitis (1 vs. 3) and post-ERCP pancreatitis (0 vs. 2). No stent- or procedure-related deaths occurred.

Conclusions: Endotherapy of CP-associated BBS has similar efficacy and safety for 12-month treatment using MPS compared to a single FCSEMS, with FCSEMS requiring fewer ERCPs over 2 years. (ClinicalTrials.gov, Number: NCT01543256).
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http://dx.doi.org/10.1053/j.gastro.2021.03.015DOI Listing
March 2021

Aggressive fluid hydration plus non-steroidal anti-inflammatory drugs versus non-steroidal anti-inflammatory drugs alone for post-endoscopic retrograde cholangiopancreatography pancreatitis (FLUYT): a multicentre, open-label, randomised, controlled trial.

Lancet Gastroenterol Hepatol 2021 May 19;6(5):350-358. Epub 2021 Mar 19.

Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands. Electronic address:

Background: Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Prophylactic rectal administration of non-steroidal anti-inflammatory drugs (NSAIDs) is considered as standard of care to reduce the risk of post-ERCP pancreatitis. It has been suggested that aggressive hydration might further reduce this risk. Guidelines already recommend aggressive hydration in patients who are unable to receive rectal NSAIDs, although it is laborious and time consuming. We aimed to evaluate the added value of aggressive hydration in patients receiving prophylactic rectal NSAIDs.

Methods: FLUYT, a multicentre, open-label, randomised, controlled trial done across 22 Dutch hospitals, included patients aged between 18 and 85 years with moderate to high risk of post-ERCP pancreatitis. Patients were randomly assigned (1:1) by a web-based module with varying block sizes to a combination of aggressive hydration and rectal NSAIDs (100 mg diclofenac or indomethacin; aggressive hydration group) or rectal NSAIDs (100 mg diclofenac or indomethacin) alone (control group). Randomisation was stratified according to treatment centre. Aggressive hydration comprised 20 mL/kg intravenous Ringer's lactate solution within 60 min from the start of ERCP, followed by 3 mL/kg per h for 8 h. The control group received normal intravenous saline with a maximum of 1·5 mL/kg per h and 3 L per 24 h. The primary endpoint was post-ERCP pancreatitis and was analysed on a modified intention-to-treat basis (including all patients who underwent randomisation and an ERCP and for whom data regarding the primary outcome were available). The trial is registered with the ISRCTN registry, ISRCTN13659155.

Findings: Between June 5, 2015, and June 6, 2019, 826 patients were randomly assigned, of whom 388 in the aggressive hydration group and 425 in the control group were included in the modified intention-to-treat analysis. Post-ERCP pancreatitis occurred in 30 (8%) patients in the aggressive hydration group and in 39 (9%) patients in the control group (relative risk 0·84, 95% CI 0·53-1·33, p=0·53). There were no differences in serious adverse events, including hydration-related complications (relative risk 0·99, 95% CI 0·59-1·64; p=1·00), ERCP-related complications (0·90, 0·62-1·31; p=0·62), intensive care unit admission (0·37, 0·07-1·80; p=0·22), and 30-day mortality (0·95, 0·50-1·83; p=1·00).

Interpretation: Aggressive periprocedural hydration did not reduce the incidence of post-ERCP pancreatitis in patients with moderate to high risk of developing this complication who routinely received prophylactic rectal NSAIDs. Therefore, the burden of laborious and time-consuming aggressive periprocedural hydration to further reduce the risk of post-ERCP pancreatitis is not justified.

Funding: Netherlands Organisation for Health Research and Development and Radboud University Medical Center.
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http://dx.doi.org/10.1016/S2468-1253(21)00057-1DOI Listing
May 2021

Prevalence of and risk factors for stent migration-induced duodenal perforation.

Endosc Int Open 2021 Mar 19;9(3):E461-E469. Epub 2021 Feb 19.

Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.

The safety of transpapillary biliary drainage by stent placement through endoscopic retrograde cholangiography (ERC) may be compromised by the occurrence of stent migration-induced perforation of the duodenal wall (SMDP). We aimed to assess the prevalence rate, risk factors and clinical course of SMDP. This retrospective cohort study included all patients who underwent an ERC with biliary plastic stent placement, between January 2014 and December 2018. Patients with an SMDP were identified from our endoscopy complication registry.  1227 patients underwent an ERC, of whom 629 patients (51 %) with biliary plastic stent placement; in 304 patients (25 %) stents were placed for perihilar strictures. Thirteen patients with SMDP were identified. The prevalence was 2.1 % for patients with biliary plastic stent placement and 4.3 % for patients stented for a perihilar stricture. All SMDPs occurred in patients with a perihilar stricture and with stents ≥ 12 cm (range 12-20 cm). Another potential risk factor was stent insertion into the left liver lobe, which was present in 10 of 13 patients. In 10 of 13 patients, SMDP was clinically suspected. Three of 13 patients were asymptomatic and diagnosed at elective stent retrieval. Eight patients could be endoscopically treated with an over-the-scope clip. Four patients died due to abdominal sepsis despite repeated interventions.  SMDP is a rare but potentially life-threatening complication of ERC after transpapillary drainage for perihilar biliary strictures. Stents ≥ 12 cm and stent insertion into the left liver lobe may be associated risk factors.
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http://dx.doi.org/10.1055/a-1337-2321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7895667PMC
March 2021

Factors associated with the progression of gastric intestinal metaplasia: a multicenter, prospective cohort study.

Endosc Int Open 2021 Mar 18;9(3):E297-E305. Epub 2021 Feb 18.

Departments of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands.

Gastric cancer (GC) is usually preceded by premalignant gastric lesions (GPLs) such as gastric intestinal metaplasia (GIM). Information on risk factors associated with neoplastic progression of GIM are scarce. This study aimed to identify predictors for progression of GIM in areas with low GC incidence. The Progression and Regression of Precancerous Gastric Lesions (PROREGAL) study includes patients with GPL. Patients underwent at least two upper endoscopies with random biopsy sampling. Progression of GIM means an increase in severity according to OLGIM (operative link on gastric intestinal metaplasia) during follow-up (FU). Family history and lifestyle factors were determined through questionnaires. Serum infection, pepsinogens (PG), gastrin-17 and GC-associated single nucleotide polymorphisms (SNPs) were determined. Cox regression was performed for risk analysis and a chi-squared test for analysis of single nucleotide polymorphisms. Three hundred and eight patients (median age at inclusion 61 years, interquartile range (IQR: 17; male 48.4 %; median FU 48 months, IQR: 24) were included. During FU, 116 patients (37.7 %) showed progression of IM and six patients (1.9 %) developed high-grade dysplasia or GC. The minor allele (C) on (rs11536889) was inversely associated with progression of GIM (OR 0.6; 95 %CI 0.4-1.0). Family history (HR 1.5; 95 %CI 0.9-2.4) and smoking (HR 1.6; 95 %CI 0.9-2.7) showed trends towards progression of GIM. Alcohol use, body mass index, history of infection, and serological markers were not associated with progression. Family history and smoking appear to be related to an increased risk of GIM progression in low GC incidence countries. (rs11536889) showed a significant inverse association, suggesting that genetic information may play a role in GIM progression.
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http://dx.doi.org/10.1055/a-1314-6626DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7892268PMC
March 2021

Identifying key factors for the effectiveness of pancreatic cancer screening: A model-based analysis.

Int J Cancer 2021 Feb 28. Epub 2021 Feb 28.

Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.

Pancreatic cancer (PC) survival is poor, as detection usually occurs late, when treatment options are limited. Screening of high-risk individuals may enable early detection and a more favorable prognosis. Knowledge gaps prohibit establishing the effectiveness of screening. We developed a Microsimulation Screening Analysis model to analyze the impact of relevant uncertainties on the effect of PC screening in high-risk individuals. The model simulates two base cases: one in which lesions always progress to PC and one in which indolent and faster progressive lesions coexist. For each base case, the effect of annual and 5-yearly screening with endoscopic ultrasonography/magnetic resonance imaging was evaluated. The impact of variance in PC risk, screening test characteristics and surgery-related mortality was evaluated using sensitivity analyses. Screening resulted in a reduction of PC mortality by at least 16% in all simulated scenarios. This reduction depended strongly on the natural disease course (annual screening: -57% for "Progressive-only" vs -41% for "Indolent Included"). The number of screen and surveillance tests needed to prevent one cancer death was impacted most by PC risk. A 10% increase in test sensitivity reduced mortality by 1.9% at most. Test specificity is important for the number of surveillance tests. In conclusion, screening reduces PC mortality in all modeled scenarios. The natural disease course and PC risk strongly determines the effectiveness of screening. Test sensitivity seems of lesser influence than specificity. Future research should gain more insight in PC pathobiology to establish the true value of PC screening in high-risk individuals.
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http://dx.doi.org/10.1002/ijc.33540DOI Listing
February 2021

Increased Use of Prophylactic Measures in Preventing Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis.

Dig Dis Sci 2021 Feb 25. Epub 2021 Feb 25.

Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands.

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs), pancreatic duct stenting, and intensive intravenous hydration have been proven to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Trial participation and guideline changes demanded an assessment of the clinical practice of post-ERCP pancreatitis prophylaxis.

Aims: The surveys aim to identify points of improvement to inform and educate ERCPists about current evidence-based practice.

Methods: Two anonymous surveys were conducted among Dutch gastroenterologists in 2013 (n = 408) and 2020 (n = 575) for longitudinal views and attitudes pertaining to post-ERCP pancreatitis prophylaxis and recognition of post-ERCP pancreatitis risk factors.

Results: In 2013 and 2020, respectively, 121 and 109 ERCPists responded. In the 2013 survey, 98% of them utilized NSAID prophylaxis and 62% pancreatic duct stent prophylaxis in specific cases. In the 2020 survey, the use of NSAIDs (100%), pancreatic duct stents (78%), and intensive intravenous hydration (33%) increased among ERCPists. NSAID prophylaxis was the preferred prophylactic measure for all risk factors in the 2020 survey, except for ampullectomy, pancreatic duct contrast injection, and pancreatic duct cannulation, for which NSAID prophylaxis and pancreatic duct stent combined was equally favored or preferred.

Conclusion: Rectal NSAIDs are the most applied post-ERCP pancreatitis prophylaxis in the Netherlands, followed by pancreatic duct stents and intensive intravenous hydration. Additionally, there is reason to believe that recent guideline updates and active research participation have led to increased prophylaxis implementation.
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http://dx.doi.org/10.1007/s10620-020-06796-0DOI Listing
February 2021

Individual risk calculator to predict lymph node metastases in patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study.

Endoscopy 2021 Feb 24. Epub 2021 Feb 24.

Erasmus MC, Gastroenterology and Hepatology, Rotterdam, Netherlands.

There is a risk for lymph node metastases (LNM) after endoscopic resection of early esophageal adenocarcinoma (EAC). The aim of this study was to develop and internally validate a prediction model that estimates the individual metastases risk in patients with pT1b EAC. This is a nationwide, retrospective, multicenter cohort study. Patients with pT1b EAC and treated with endoscopic resection and/or surgery between 1989 and 2016 were included. Primary endpoint was the presence of LNM in surgical resection specimen or the detection of metastases during follow-up. All resection specimens were histologically reassessed by specialized gastrointestinal pathologists. Subdistribution hazard regression analysis was used to develop a prediction model. The discriminative ability of this model was assessed using the c-statistic. 248 patients with pT1b EAC were included. Metastases were seen in 78 patients, and the 5-year cumulative incidence was 30.9% (95% CI 25.1%-36.8%). The risk for metastases increased with submucosal invasion depth (subdistribution hazard ratio [SHR] 1.08, 95% CI 1.02-1.14, for every increase of 500 μm), for tumors with lymphovascular invasion (SHR 2.95, 95% CI 1.95-4.45) and for larger tumors (SHR 1.23, 95% CI 1.10-1.37, for every increase of 10 mm). The model demonstrated a good discriminative ability (c-statistic 0.81, 95% CI 0.75-0.86). One third of patients with pT1b EAC experienced metastases within 5 years. The probability for developing post resection metastases can be estimated with a personalized predicted risk score incorporating tumor invasion depth, tumor size and lymphovascular invasion. This model needs to be externally validated before implementation into clinical practice.
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http://dx.doi.org/10.1055/a-1399-4989DOI Listing
February 2021

Estimating global prevalence of metabolic dysfunction-associated fatty liver disease in overweight or obese adults.

Clin Gastroenterol Hepatol 2021 Feb 19. Epub 2021 Feb 19.

Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, The Netherlands; Biomedical Research Center, Northwest Minzu University, Lanzhou, China. Electronic address:

Background & Aims: Metabolic dysfunction-associated fatty liver disease (MAFLD) is a new terminology updated from non-alcoholic fatty liver disease (NAFLD). In this study, we aim to estimate the global prevalence of MAFLD specifically in overweight and obese adults from the general population by performing a systematic review and meta-analysis through mining the existing epidemiological data on fatty liver disease.

Methods: We searched Medline, Embase, Web of Science, Cochrane and google scholar database from inception to November, 2020. DerSimonian-Laired random-effects model with Logit transformation was performed for data analysis. Sensitivity analysis and meta-regression were used to explore predictors of MAFLD prevalence in pooled statistics with high heterogeneity.

Results: We identified 116 relevant studies comprised of 2667052 participants in general population with an estimated global MAFLD prevalence as 50.7% (95% CI 46.9-54.4) among overweight/obese adults regardless of diagnostic techniques. Ultrasound was the most commonly used diagnostic technique generating prevalence rate of 51.3% (95% CI 49.1-53.4). Male (59.0%, 95% CI 52.0-65.6) had a significantly higher MAFLD prevalence than female (47.5%, 95% CI 40.7-54.5). Interestingly, MAFLD prevalence rates are comparable based on classical NAFLD and non-NAFLD studies in general population. The pooled estimate prevalence of comorbidities such as type 2 diabetes and metabolic syndrome was 19.7% (95% CI 12.8-29.0) and 57.5% (95% CI 49.9-64.8), respectively.

Conclusion: MAFLD has an astonishingly high prevalence rate in overweight and obese adults. This calls for attention and dedicated action from primary care physicians, specialists, health policy makers and the general public alike.
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http://dx.doi.org/10.1016/j.cgh.2021.02.030DOI Listing
February 2021

Accuracy of upper endoscopies with random biopsies to identify patients with gastric premalignant lesions who can safely be exempt from surveillance.

Gastric Cancer 2021 Feb 22. Epub 2021 Feb 22.

Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands.

Introduction: Guidelines recommend endoscopy with biopsies to stratify patients with gastric premalignant lesions (GPL) to high and low progression risk. High-risk patients are recommended to undergo surveillance. We aimed to assess the accuracy of guideline recommendations to identify low-risk patients, who can safely be discharged from surveillance.

Methods: This study includes patients with GPL. Patients underwent at least two endoscopies with an interval of 1-6 years. Patients were defined 'low risk' if they fulfilled requirements for discharge, and 'high risk' if they fulfilled requirements for surveillance, according to European guidelines (MAPS-2012, updated MAPS-2019, BSG). Patients defined 'low risk' with progression of disease during follow-up (FU) were considered 'misclassified' as low risk.

Results: 334 patients (median age 60 years IQR11; 48.7% male) were included and followed for a median of 48 months. At baseline, 181/334 (54%) patients were defined low risk. Of these, 32.6% were 'misclassified', showing progression of disease during FU. If MAPS-2019 were followed, 169/334 (51%) patients were defined low risk, of which 32.5% were 'misclassified'. If BSG were followed, 174/334 (51%) patients were defined low risk, of which 32.2% were 'misclassified'. Seven patients developed gastric cancer (GC) or dysplasia, four patients were 'misclassified' based on MAPS-2012 and three on MAPS-2019 and BSG. By performing one additional endoscopy 72.9% (95% CI 62.4-83.3) of high-risk patients and all patients who developed GC or dysplasia were identified.

Conclusion: One-third of patients that would have been discharged from GC surveillance, appeared to be 'misclassified' as low risk. One additional endoscopy will reduce this risk by 70%.
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http://dx.doi.org/10.1007/s10120-020-01149-2DOI Listing
February 2021

Diagnosis and treatment of pancreatic duct disruption or disconnection: an international expert survey and case vignette study.

HPB (Oxford) 2021 Jan 19. Epub 2021 Jan 19.

Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands. Electronic address:

Background: Pancreatic duct disruption or disconnection is a potentially severe complication of necrotizing pancreatitis. With no existing treatment guidelines, it is unclear whether there is any consensus among experts in clinical practice. We evaluated current expert opinion regarding the diagnosis and treatment of pancreatic duct disruption and disconnection in an international case vignette study.

Methods: An online case vignette survey was sent to 110 international expert pancreatologists. Expert selection was based on publications in the last 5 years and/or participation in development of IAP/APA and ESGE guidelines on acute pancreatitis. Consensus was defined as agreement by at least 75% of the experts.

Results: The response rate was 51% (n = 56). Forty-four experts (79%) obtained a MRI/MRCP and 52 experts (93%) measured amylase levels in percutaneous drain fluid to evaluate pancreatic duct integrity. The majority of experts favored endoscopic transluminal drainage for infected (peri)pancreatic necrosis and pancreatic duct disruption (84%, n = 45) or disconnection (88%, n = 43). Consensus was lacking regarding the treatment of patients with persistent percutaneous drain production, and with persistent sterile necrosis.

Conclusion: This international survey of experts demonstrates that there are many areas for which no consensus existed, providing clear focus for future investigation.
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http://dx.doi.org/10.1016/j.hpb.2020.11.1148DOI Listing
January 2021

Favorable effect of endoscopic reassessment of clinically staged T2 esophageal adenocarcinoma: a multicenter, prospective cohort study.

Endoscopy 2021 Feb 2. Epub 2021 Feb 2.

Erasmus MC Cancer Institute, University Medical Center Rotterdam, Gastroenterology and Hepatology, Rotterdam, Netherlands.

Clinical tumor stage of esophageal adenocarcinoma (EAC) is determined by endoscopic ultrasound and/or CT-scan. The accuracy of these tools is low for stages T1 and T2, which may result in overtreatment. We aimed to assess the proportion of cT2 EAC downstaged to cT1 after endoscopic reassessment (ERA) by an experienced interventional endoscopist. We performed a prospective multicenter cohort study. Patients with cT2N0M0 EAC were included and underwent ERA. Primary endpoint was the proportion of cT2 EAC downstaged to cT1 after ERA. Fifteen (60%) of 25 included patients were downstaged from cT2 to cT1 EAC after ERA, all underwent an attempt at endoscopic resection (ER). ER was aborted in 3 of 15 patients due to tumor invasion in the muscle layer, all underwent successful surgical resection. ER was successful in 12/15 (80%) patients, all pT1 tumors. Ten of 25 (40%) patients were treated with ER only. ERA downstages about half of the cT2 tumors to cT1 suitable for ER. ERA has a substantial clinical impact on therapeutic management preventing overtreatment in 40% of patients.
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http://dx.doi.org/10.1055/a-1380-8899DOI Listing
February 2021

The Management of Peutz-Jeghers Syndrome: European Hereditary Tumour Group (EHTG) Guideline.

J Clin Med 2021 Jan 27;10(3). Epub 2021 Jan 27.

Center for Hereditary Tumors, Ev. BETHESDA Khs. Duisburg, Academic Hospital University of Düsseldorf, 47053 Duisburg, Germany.

The scientific data to guide the management of Peutz-Jeghers syndrome (PJS) are sparse. The available evidence has been reviewed and discussed by diverse medical specialists in the field of PJS to update the previous guideline from 2010 and formulate a revised practical guideline for colleagues managing PJS patients. Methods: Literature searches were performed using MEDLINE, Embase, and Cochrane. Evidence levels and recommendation strengths were assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). A Delphi process was followed, with consensus being reached when ≥80% of the voting guideline committee members agreed. Recommendations and statements: The only recent guidelines available were for gastrointestinal and pancreatic management. These were reviewed and endorsed after confirming that no more recent relevant papers had been published. Literature searches were performed for additional questions and yielded a variable number of relevant papers depending on the subject addressed. Additional recommendations and statements were formulated. Conclusions: A decade on, the evidence base for recommendations remains poor, and collaborative studies are required to provide better data about this rare condition. Within these restrictions, multisystem, clinical management recommendations for PJS have been formulated.
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http://dx.doi.org/10.3390/jcm10030473DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7865862PMC
January 2021

The Potential of Soluble Human Leukocyte Antigen Molecules for Early Cancer Detection and Therapeutic Vaccine Design.

Vaccines (Basel) 2020 Dec 18;8(4). Epub 2020 Dec 18.

Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands.

Human leukocyte antigen (HLA) molecules are essential for anti-tumor immunity, as they display tumor-derived peptides to drive tumor eradication by cytotoxic T lymphocytes. HLA molecules are primarily studied as peptide-loaded complexes on cell membranes (mHLA) and much less attention is given to their secretion as soluble HLA-peptide complexes (sHLA) into bodily fluids. Yet sHLA levels are altered in various pathologies including cancer, and are thus of high interest as biomarkers. Disconcordance in results across studies, however, hampers interpretation and generalization of the relationship between sHLA levels and cancer presence, thereby impairing its use as a biomarker. Furthermore, the question remains to what extent sHLA complexes exert immunomodulatory effects and whether shifts in sHLA levels contribute to disease or are only a consequence of disease. sHLA complexes can also bear tumor-derived peptides and recent advancements in mass spectrometry now permit closer sHLA peptide cargo analysis. sHLA peptide cargo may represent a "liquid biopsy" that could facilitate the use of sHLA for cancer diagnosis and target identification for therapeutic vaccination. This review aims to outline the contradictory and unexplored aspects of sHLA and to provide direction on how the full potential of sHLA as a quantitative and qualitative biomarker can be exploited.
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http://dx.doi.org/10.3390/vaccines8040775DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7766713PMC
December 2020

Uncommon cause of cholangitis due to a migrated pancreatic stone into the common bile duct.

VideoGIE 2020 Dec 18;5(12):667-669. Epub 2020 Aug 18.

Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.

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http://dx.doi.org/10.1016/j.vgie.2020.07.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7730134PMC
December 2020

Increased risk of second primary tumours in patients with oesophageal squamous cell carcinoma: A nationwide study in a Western population.

United European Gastroenterol J 2020 Dec 3:2050640620977129. Epub 2020 Dec 3.

Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands.

Background: Patients with primary oesophageal squamous cell carcinoma are at risk of developing multiple primary tumours in the upper aero digestive tract. To date, most studies are performed in the Asian population. We aimed to evaluate the risk of multiple primary tumours in the upper aero digestive tract and stomach in patients with oesophageal squamous cell carcinoma in a Western population.

Methods: We performed a nationwide, retrospective cohort study in collaboration with the Netherlands Cancer Registry. Patients with primary oesophageal squamous cell carcinoma, diagnosed between 2000-2016, were included. Primary endpoints were synchronous and metachronous multiple primary tumour risk.

Results: The cohort consisted of 9058 patients, diagnosed with oesophageal squamous cell carcinoma (male: 57.3%, median age 67 years). In 476 patients (5.3%), 545 multiple primary tumours have been diagnosed. Most of them were located in the head and neck region (49.5%). Among all multiple primary tumours, 329 (60.4%) were diagnosed synchronously (<6 months after oesophageal squamous cell carcinoma diagnosis) and 216 (39.6%) metachronously (≥6 months). Patients with oesophageal squamous cell carcinoma had a significantly increased risk of both synchronous (standardised incidence ratio 10.95, 99% confidence interval 9.40-12.53) and metachronous multiple primary tumours (standardised incidence ratio 4.36, 99% confidence interval 3.56-5.10), compared to the general population. The median interval to metachronous second primary tumour diagnosis was 3.0 years (interquartile range 1.8-5.9).

Conclusion: Approximately one in 20 patients with primary oesophageal squamous cell carcinoma have a second primary tumour in the upper aero digestive tract or stomach, either at the time of oesophageal squamous cell carcinoma diagnosis or at a later stage. As second primary tumours occur at an increased risk compared to the general population, prospective studies are necessary to investigate the yield and survival benefit of screening for second primary tumours in patients with oesophageal squamous cell carcinoma.
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http://dx.doi.org/10.1177/2050640620977129DOI Listing
December 2020

Effectiveness of topical budesonide in preventing esophageal strictures after endoscopic resection of esophageal cancer.

Endosc Int Open 2020 Dec 17;8(12):E1795-E1803. Epub 2020 Nov 17.

Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.

A disadvantage of endoscopic resection (ER) of early esophageal cancer (EC) is the high stricture rate after resection. A risk factor for stricture development is a mucosal defect after ER of ≥ 75 % of the esophageal circumference. Stricture rates up to 94 % have been reported in these patients. The aim of this study was to investigate the effectiveness of oral treatment with topical budesonide for stricture prevention after ER of early EC. We performed a retrospective analysis of a prospective cohort study of patients who received topical budesonide after ER of EC between March 2015 and April 2020. The primary endpoint was the esophageal stricture rate after ER. Stricture rates of our cohort were compared with stricture rates of control groups in the literature. In total, 42 patients were treated with ER and topical budesonide. A total of 18 of 42 patients (44.9 %) developed a stricture. The pooled stricture rate of control groups in the literature was 75.3 % (95 % CI 68.8 %-81.9 %). Control groups consisted of patients with esophageal squamous cell carcinoma with a mucosal defect after ER of ≥ 75 % of the esophageal circumference. Comparable patients of our cohort had a lower stricture rate (47.8 % vs. 75.3 %,  = 0.007). Topical budesonide therapy after ER for EC seems to be a safe and effective method in preventing strictures. The stricture rate after budesonide treatment is lower compared to the stricture rate of patients who did not receive a preventive treatment after ER reported in the literature.
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http://dx.doi.org/10.1055/a-1266-3423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671763PMC
December 2020

Mesenteric artery calcium scoring: a potential screening method for chronic mesenteric ischemia.

Eur Radiol 2020 Dec 2. Epub 2020 Dec 2.

Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands.

Objective: A practical screening tool for chronic mesenteric ischemia (CMI) could facilitate early recognition and reduce undertreatment and diagnostic delay. This study explored the ability to discriminate CMI from non-CMI patients with a mesenteric artery calcium score (MACS).

Methods: This retrospective study included CTAs of consecutive patients with suspected CMI in a tertiary referral center between April 2016 and October 2019. A custom-built software module, using the Agatston definition, was developed and used to calculate the MACS for the celiac artery (CA), superior mesenteric artery (SMA), and inferior mesenteric artery. Scoring was performed by two blinded observers. Interobserver agreement was determined using 39 CTAs scored independently by both observers. CMI was defined as sustained symptom improvement after treatment. Non-CMI patients were patients not diagnosed with CMI after a diagnostic workup and patients not responding to treatment.

Results: The MACS was obtained in 184 patients, 49 CMI and 135 non-CMI. Interobserver agreement was excellent (intraclass correlation coefficient 0.910). The MACS of all mesenteric arteries was significantly higher in CMI patients than in non-CMI patients. ROC analysis of the combined MACS of CA + SMA showed an acceptable AUC (0.767), high sensitivity (87.8%), and high NPV (92.1%), when using a ≥ 29.7 CA + SMA MACS cutoff. Comparison of two CTAs, obtained in the same patient at different points in time with different scan and reconstruction parameters, was performed in 29 patients and revealed significant differences in MACSs.

Conclusion: MACS seems a promising screening method for CMI, but correction for scan and reconstruction parameters is warranted.

Key Points: • A mesenteric artery calcium score obtained in celiac artery and superior mesenteric artery has a high negative predictive value for chronic mesenteric ischemia and could serve as a screening tool. • Interobserver agreement of the mesenteric artery calcium score is excellent. • Scan and reconstruction parameters influence the mesenteric artery calcium score and warrant the development of a method to correct for these parameters.
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http://dx.doi.org/10.1007/s00330-020-07530-0DOI Listing
December 2020

Pain patterns in chronic pancreatitis: a nationwide longitudinal cohort study.

Gut 2020 Nov 6. Epub 2020 Nov 6.

Department of Surgery, University Medical Centre, Utrecht, The Netherlands

Objective: Pain in chronic pancreatitis is subdivided in a continuous or intermittent pattern, each thought to represent a different entity, requiring specific treatment. Because evidence is missing, we studied pain patterns in a prospective longitudinal nationwide study.

Design: 1131 patients with chronic pancreatitis (fulfilling M-ANNHEIM criteria) were included between 2011 and 2018 in 30 Dutch hospitals. Patients with continuous or intermittent pain were compared for demographics, pain characteristics, quality of life (Short-Form 36), imaging findings, disease duration and treatment. Alternation of pain pattern and associated variables were longitudinally assessed using a multivariable multinomial logistic regression model.

Results: At inclusion, 589 patients (52%) had continuous pain, 231 patients (20%) had intermittent pain and 311 patients (28%) had no pain. Patients with continuous pain had more severe pain, used more opioids and neuropathic pain medication, and had a lower quality of life. There were no differences between pain patterns for morphological findings on imaging, disease duration and treatment. During a median follow-up of 47 months, 552 of 905 patients (61%) alternated at least once between pain patterns. All alternations were associated with the Visual Analogue Scale pain intensity score and surgery was only associated with the change from pain to no pain.

Conclusion: Continuous and intermittent pain patterns in chronic pancreatitis do not seem to be the result of distinctly different pathophysiological entities. The subjectively reported character of pain is not related to imaging findings or disease duration. Pain patterns often change over time and are merely a feature of how severity of pain is experienced.
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http://dx.doi.org/10.1136/gutjnl-2020-322117DOI Listing
November 2020

Confocal endomicroscopy for evaluation of pancreatic cystic lesions: a systematic review and international Delphi consensus report.

Endosc Int Open 2020 Nov 22;8(11):E1566-E1581. Epub 2020 Oct 22.

Division of Gastroenterology Mount Auburn Hospital Cambridge, Massachusetts, United States.

The aim of thi systematic review and consensus report is to standardize the practice of endoscopic ultrasound (EUS-guided needle-based confocal laser endomicroscopy (nCLE) for pancreatic cystic lesion (PCL) evaluation. We performed an international, systematic, evidence-based review of the applications, outcomes, procedural processes, indications, training, and credentialing of EUS-nCLE in management of PCLs. Based on available clinical evidence, preliminary nCLE consensus statements (nCLE-CS) were developed by an international panel of 15 experts in pancreatic diseases. These statements were then voted and edited by using a modified Delphi approach. An a priori threshold of 80 % agreement was used to establish consensus for each statement. Sixteen nCLE-CS were discussed. Thirteen (81 %) nCLE-CS reached consensus addressing indications (non-communication PCL meeting criteria for EUS-FNA or with prior non-diagnostic EUS-FNA), diagnostic outcomes (improved accuracy for mucinous PCLs and serous cystadenomas with substantial interobserver agreement of image patterns), low incidence of adverse events (fluorescein-associated and pancreatitis), procedural processes (nCLE duration, manipulation of needle with probe), and training (physician knowledge and competence). Based on a high level of agreement pertaining to expert consensus statements, this report standardizes the practice of EUS-nCLE. EUS-nCLE should be systematically considered when EUS-FNA is indicated for PCL evaluation.
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http://dx.doi.org/10.1055/a-1229-4156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7581463PMC
November 2020

Optimization of Pancreatic Juice Collection: A First Step Toward Biomarker Discovery and Early Detection of Pancreatic Cancer.

Am J Gastroenterol 2020 12;115(12):2103-2108

Department of Gastroenterology & Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.

Introduction: Imaging-based surveillance programs fail to detect pancreatic ductal adenocarcinoma at a curable stage, creating an urgent need for diagnostic biomarkers.

Methods: Secretin-stimulated pancreatic juice (PJ) was collected from the duodenal lumen during endoscopic ultrasound. The yield of biomarkers and organoids was compared for 2 collection techniques (endoscope suction channel vs catheter-based) and 3 periods (0-4 vs 4-8 vs 8-15 minutes).

Results: Collection through the endoscope suction channel was superior to collection with a catheter. Collection beyond 8 minutes reduced biomarker yield. PJ-derived organoid culture was feasible.

Discussion: The optimal protocol for secretin-stimulated PJ collection is through the endoscope suction channel for 8 minutes allowing biomarker detection and organoid culture.
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http://dx.doi.org/10.14309/ajg.0000000000000939DOI Listing
December 2020

Optimizing cytological specimens of EUS-FNA of solid pancreatic lesions: A pilot study to the effect of a smear preparation training for endoscopy personnel on sample quality and accuracy.

Diagn Cytopathol 2021 Feb 24;49(2):295-302. Epub 2020 Oct 24.

Department of Pathology, Erasmus MC University Medical Center Rotterdam, the Netherlands and Institute for Pathology, Dueren, Germany.

Background: In the absence of rapid on-side pathological evaluation, endoscopy staff generally "smears" endoscopic ultrasound guided fine needle aspiration (EUS-FNA) specimens on a glass slide. As this technique is vulnerable to preparation artifacts, we assessed if its quality could be improved through a smear-preparation-training for endoscopy staff.

Methods: In this prospective pilot study, 10 endosonographers and 12 endoscopy nurses from seven regional EUS-centers in the Netherlands were invited to participate in a EUS-FNA smear-preparation-training. Subsequently, post training slides derived from solid pancreatic lesions were compared to pre-training "control" slides. Primary outcome was to assess if the training positively affects smear quality and, consequently, diagnostic accuracy of EUS-FNA of solid pancreatic lesions.

Results: Participants collected and prepared 71 cases, mostly pancreatic head lesions (48%). Sixty-eight controls were selected from the pretraining period. The presence of artifacts was comparable for smears performed before and after training (76% vs 82%, P = .36). Likewise, smear cellularity (≥50% target cells) before and after training did not differ (44% (30/68) vs 49% (35/71), P = .48). Similar, no difference in diagnostic accuracy for malignancy was detected (P = .10).

Conclusion: In this pilot EUS-FNA smear-preparation-training for endoscopy personnel, smear quality and diagnostic accuracy were not improved after the training. Based on these results, we plan to further study other training programs and possibilities.
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http://dx.doi.org/10.1002/dc.24645DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7820998PMC
February 2021

Impact of the COVID-19 pandemic on gastrointestinal endoscopy in the Netherlands: analysis of a prospective endoscopy database.

Endoscopy 2021 Feb 20;53(2):166-170. Epub 2020 Oct 20.

Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.

Background:  COVID-19 has dramatically affected gastrointestinal endoscopy practice. We aimed to investigate its impact on procedure types, indications, and findings.

Methods:  We retrospectively analyzed endoscopies performed in 15 Dutch hospitals by comparing periods 15 March to 25 June of 2019 and 2020 using the prospective Trans.IT database.

Results:  During lockdown in 2020, 9776 patients underwent endoscopy compared with 19 296 in 2019. Gastroscopies decreased by 57 % (from 7846 to 4467) and colonoscopies by 45 % (from 12219 to 5609), whereas endoscopic retrograde cholangiopancreatography volumes remained comparable (from 578 to 522). Although endoscopy results indicative of cancer decreased (from 524 to 340), the likelihood of detecting cancer during endoscopy increased (2.7 % [95 % confidence interval (CI) 2.5 - 3.0] in 2019 versus 3.5 % [95 %CI 3.1 - 3.9] in 2020;  < 0.001). After lifting of lockdown, endoscopy volumes started to return to normal, except for colorectal cancer screening.

Conclusions:  Fewer endoscopies were performed during the COVID-19 lockdown, leading to a significant reduction in the absolute detection of cancer. Endoscopies increased rapidly after lockdown, except for colorectal cancer screening.
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http://dx.doi.org/10.1055/a-1272-3788DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869035PMC
February 2021

Nationwide compliance with a multidisciplinary guideline on pancreatic cancer during 6-year follow-up.

Pancreatology 2020 Dec 10;20(8):1723-1731. Epub 2020 Oct 10.

Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands. Electronic address:

Background: Compliance with national guidelines on pancreatic cancer management could improve patient outcomes. Early compliance with the Dutch guideline was poor. The aim was to assess compliance with this guideline during six years after publication.

Materials And Methods: Nationwide guideline compliance was investigated for three subsequent time periods (2012-2013 vs. 2014-2015 vs. 2016-2017) in patients with pancreatic cancer using five quality indicators in the Netherlands Cancer Registry: 1) discussion in multidisciplinary team meeting (MDT), 2) maximum 3-week interval from final MDT to start of treatment, 3) preoperative biliary drainage when bilirubin >250 μmol/L, 4) use of adjuvant chemotherapy, and 5) chemotherapy for inoperable disease (non-metastatic and metastatic).

Results: In total, 14 491 patients were included of whom 2290 (15.8%) underwent resection and 4561 (31.5%) received chemotherapy. Most quality indicators did not change over time: overall, 88.8% of patients treated with curative intent were discussed in a MDT, 42.7% were treated with curative intent within the 3-week interval, 62.7% with a resectable head tumor and bilirubin >250 μmol/L underwent preoperative biliary drainage, 57.2% received chemotherapy after resection, and 36.6% with metastatic disease received chemotherapy. Only use of chemotherapy for non-metastatic, non-resected disease improved over time (23.4% vs. 25.6% vs. 29.7%).

Conclusion: Nationwide compliance to five quality indicators for the guideline on pancreatic cancer management showed little to no improvement during six years after publication. Besides critical review of the current quality indicators, these outcomes may suggest that a nationwide implementation program is required to increase compliance to guideline recommendations.
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http://dx.doi.org/10.1016/j.pan.2020.10.032DOI Listing
December 2020

The Incidence of Chronic Mesenteric Ischemia in the Well-Defined Region of a Dutch Mesenteric Ischemia Expert Center.

Clin Transl Gastroenterol 2020 08;11(8):e00200

Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands.

Introduction: This study aimed to determine the incidence of chronic mesenteric ischemia (CMI) and to examine the influence of the etiological cause, location, and severity of a mesenteric artery stenosis on the probability of having CMI.

Methods: A prospective database, containing the details of all patients with suspected CMI referred to a renowned CMI expert center, was used. Patients residing within the expert centers' well-defined region, between January 2014 and October 2019, were included. CMI was diagnosed when patients experienced sustained symptom improvement after treatment.

Results: This study included 358 patients, 75 had a ≥50% atherosclerotic stenosis of 1 vessel (CMI 16%), 96 of 2 or 3 vessels (CMI 81%), 81 celiac artery compression (CMI 25%), and 84 no stenosis (CMI 12%). In total, 138 patients were diagnosed with CMI, rendering a mean incidence of 9.2 (95% confidence interval [CI] 6.2-13.7) per 100,000 inhabitants. Atherosclerotic CMI was most common, with a mean incidence of 7.2 (95% CI 4.6-11.3), followed by median arcuate ligament syndrome 1.3 (95% CI 0.5-3.6) and chronic nonocclusive mesenteric ischemia 0.6 (95% CI 0.2-2.6). The incidence of CMI was highest in female patients (female patients 12.0 [95% CI 7.3-19.6] vs male patients 6.5 [95% CI 3.4-12.5]) and increased with age. CMI was more prevalent in the presence of a ≥70% atherosclerotic single-vessel stenosis of the superior mesenteric artery (40.6%) than the celiac artery (5.6%).

Discussion: The incidence of CMI is higher than previously believed and increases with age. Probability of CMI seems highest in suspected CMI patients with multivessel disease or a ≥70% atherosclerotic single-vessel superior mesenteric artery stenosis.
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http://dx.doi.org/10.14309/ctg.0000000000000200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431271PMC
August 2020

Titanium clip migration after cholecystectomy: original technique for laparoscopic transcystic extraction when endoscopic retrograde cholangiopancreatography fails.

J Surg Case Rep 2020 Sep 10;2020(9):rjaa289. Epub 2020 Sep 10.

Hepato-Pancreato-Biliary Surgery Section, General Surgery Service, Clínica Universitaria Reina Fabiola, Universidad Católica de Córdoba, Oncativo 1248, Córdoba Capital, Argentina.

Surgical clip migration into the common bile duct (CBD) is a rare complication after laparoscopic cholecystectomy (LC). Few cases of surgical clip migration have been reported in the literature, and most of them have been successfully treated with endoscopic retrograde cholangiopancreatography (ERCP). We present a 71-year-old woman with 48 h of abdominal pain, jaundice and fever 6 years after laparoscopic cholecystectomy. She was diagnosed with common bile duct obstruction from surgical clip migration. After failure of ERCP, the patient was successfully treated with an innovative approach by laparoscopic transcystic extraction using endoscopic hose-type biopsy forceps. The presented technique was feasible and safe in expert hands, representing a valuable alternative to avoid the need of a choledochotomy in patients with unsuccessful ERCP.
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http://dx.doi.org/10.1093/jscr/rjaa289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482979PMC
September 2020

LAMS for all pancreatic fluid collections?

Authors:
Marco J Bruno

Endosc Int Open 2020 Sep 31;8(9):E1161-E1162. Epub 2020 Aug 31.

Department of Gastroenterology & Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands.

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http://dx.doi.org/10.1055/a-1135-8953DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458733PMC
September 2020

Acute pancreatitis.

Lancet 2020 09;396(10252):726-734

Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands. Electronic address:

Acute pancreatitis is an unpredictable and potentially lethal disease. The prognosis mainly depends on the development of organ failure and secondary infection of pancreatic or peripancreatic necrosis. In the past 10 years, treatment of acute pancreatitis has moved towards a multidisciplinary, tailored, and minimally invasive approach. Despite improvements in treatment and critical care, severe acute pancreatitis is still associated with high mortality rates. In this Seminar, we outline the latest evidence on diagnostic and therapeutic strategies for acute pancreatitis.
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http://dx.doi.org/10.1016/S0140-6736(20)31310-6DOI Listing
September 2020

Role of endoscopic ultrasonography in the diagnostic work-up of idiopathic acute pancreatitis (PICUS): study protocol for a nationwide prospective cohort study.

BMJ Open 2020 08 20;10(8):e035504. Epub 2020 Aug 20.

AMC, Amsterdam, North Holland, The Netherlands.

Introduction: Idiopathic acute pancreatitis (IAP) remains a dilemma for physicians as it is uncertain whether patients with IAP may actually have an occult aetiology. It is unclear to what extent additional diagnostic modalities such as endoscopic ultrasonography (EUS) are warranted after a first episode of IAP in order to uncover this aetiology. Failure to timely determine treatable aetiologies delays appropriate treatment and might subsequently cause recurrence of acute pancreatitis. Therefore, the aim of the Pancreatitis of Idiopathic origin: Clinical added value of endoscopic UltraSonography (PICUS) Study is to determine the value of routine EUS in determining the aetiology of pancreatitis in patients with a first episode of IAP.

Methods And Analysis: PICUS is designed as a multicentre prospective cohort study of 106 patients with a first episode of IAP after complete standard diagnostic work-up, in whom a diagnostic EUS will be performed. Standard diagnostic work-up will include a complete personal and family history, laboratory tests including serum alanine aminotransferase, calcium and triglyceride levels and imaging by transabdominal ultrasound, magnetic resonance imaging or magnetic resonance cholangiopancreaticography after clinical recovery from the acute pancreatitis episode. The primary outcome measure is detection of aetiology by EUS. Secondary outcome measures include pancreatitis recurrence rate, severity of recurrent pancreatitis, readmission, additional interventions, complications, length of hospital stay, quality of life, mortality and costs, during a follow-up period of 12 months.

Ethics And Dissemination: PICUS is conducted according to the Declaration of Helsinki and Guideline for Good Clinical Practice. Five medical ethics review committees assessed PICUS (Medical Ethics Review Committee of Academic Medical Center, University Medical Center Utrecht, Radboud University Medical Center, Erasmus Medical Center and Maastricht University Medical Center). The results will be submitted for publication in an international peer-reviewed journal.

Trial Registration Number: Netherlands Trial Registry (NL7066). Prospectively registered.
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http://dx.doi.org/10.1136/bmjopen-2019-035504DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7440829PMC
August 2020