Esophageal Self-Expandable Metal Stents Can Fracture in the Distal Third When Used for Post-Bariatric Surgery Complications: A Single Center Experience and Review of the Literature with Video.

Background: Esophageal self-expandable metal stents (SEMS) are an important endoscopic tool. These stents have now been adapted successfully to manage post-bariatric surgery complications such as anastomotic leaks and strictures. In centers of expertise, this has become the primary standard-of-care treatment given its minimally invasive nature, and that it results in early oral feeding, decreased hospitalization, and overall favorable outcomes. Self-expandable metal stents (SEMS) fractures are a rare complication of unknown etiology. We aimed to investigate possible causes of SEMS fractures and highlight a unique endoscopic approach utilized to manage a fractured and impaled SEMS. Methods: This is a retrospective study of consecutive patients who underwent esophageal SEMS placement between 2015-2021 at a tertiary referral center to identify fractured SEMS. Patient demographics, stent characteristics, and possible etiologies of fractured SEMS were identified. A comprehensive literature review was also conducted to evaluate all prior cases of fractured SEMS and to hypothesize fracture theories. Results: There were seven fractured esophageal SEMS, of which six were used to manage post-bariatric surgery complications. Five SEMS were deployed with their distal ends in the gastric antrum and proximal ends in the distal esophagus. All stents fractured within 9 weeks of deployment. Most stents (5/7) were at least 10 cm in length with fractures commonly occurring in the distal third of the stents (6/7). The wires of a fractured SEMS were embedded within the esophagogastric junction in one case, prompting the use of an overtube that was synchronously advanced while steadily extracting the stent. Discussion: We suggest the following four etiologies of SEMS fractures: anatomical, physiological, mechanical, and chemical. Stent curvature at the stomach incisura can lead to strain- and stress-related fatigue due to mechanical bending with exacerbation from respiratory movements. Physiologic factors (gastric body contractions) can result in repetitive squeezing of the stent, adding to metal fatigue. Intrinsic properties (long length and low axial force) may be contributing factors. Lastly, the stomach acidic environment may cause nitinol-induced chemical weakness. Despite the aforementioned theories, SEMS fracture etiology remains unclear. Until more data become available, it may be advisable to remove these stents within 6 weeks.

Impact of the Early COVID-19 Pandemic on Incidence and Outcomes of Hepatocellular Carcinoma in the United States.

INTRODUCTION: Access to hepatocellular carcinoma (HCC) surveillance and treatments were disrupted during the coronavirus disease 2019 (COVID-19) pandemic. We aimed to characterize the impact of the pandemic on HCC incidence and mortality rates, treatment, and outcomes in the United States. METHODS: Two nationwide databases, the United States Cancer Statistics and the National Vital Statistics System, were used to investigate HCC incidence and mortality between 2001 and 2020. Trends in age-adjusted incidence rate (aIR) and adjusted mortality rate (aMR) were assessed using joinpoint analysis. The 2020 aIR and aMR were projected based on the prepandemic data and compared with actual values to assess the extent of underdiagnosis. We assessed differences in HCC characteristics, treatment, and overall survival between 2020 and 2018-2019. RESULTS: The aIR of HCC in 2020 was significantly reduced compared with 2019 (5.22 vs 6.03/100K person-years [PY]), representing a 12.2% decrease compared with the predicted aIR in 2020 (5.94/100K PY). The greatest extent of underdiagnosis was observed in Black (-14.87%) and Hispanic (-14.51%) individuals and those with localized HCC (-15.12%). Individuals staged as regional or distant HCC were also less likely to receive treatment in 2020. However, there was no significant difference in short-term overall survival in 2020 compared with 2018-2019, with HCC mortality rates remaining stable (aMR: 2.76 vs 2.73/100K PY in 2020 vs 2019). DISCUSSION: The COVID-19 pandemic resulted in underdiagnosis of HCC, particularly early stage disease and racial ethnic minorities, and underuse of HCC-directed treatment. Longer follow-up is needed to determine the impact of the COVID-19 pandemic on HCC-related mortality.

The Disproportionate Rise in Pancreatic Cancer in Younger Women Is Due to a Rise in Adenocarcinoma and Not Neuroendocrine Tumors: A Nationwide Time-Trend Analysis Using 2001-2018 United States Cancer Statistics Databases.

In previous studies, a significant increase in the incidence of pancreatic cancer among younger women compared to men in the United States was noted. However, the specific histopathologic characteristics were not delineated. This population-based study aimed to assess whether this disproportionate rise in pancreatic cancer in younger women was contributed by pancreatic ductal adenocarcinoma (PDAC) or pancreatic neuroendocrine tumors (PanNET). The United States Cancer Statistics (USCS) database was used to identify patients with pancreatic cancer between 2001 and 2018. The results showed that, in younger adults, the incidence of PDAC has increased in women [average annual percentage change (AAPC) = 0.62%], while it has remained stable in men (AAPC = -0.09%). The PDAC incidence rate among women increased at a greater rate compared to men with a statistically significant difference in AAPC (p < 0.001), with neither identical nor parallel trends. In contrast, cases of PanNET did not demonstrate a statistically significant sex-specific AAPC difference. In conclusion, this study demonstrated that the dramatic increase in the incidence rate of PDAC explains the disproportionate rise in pancreatic cancer incidence in younger women. This prompts further prospective studies to investigate the underlying reasons for these sex-specific disparities in PDAC.

5-Hydroxymethylcytosine (5-hmC) loss is a marker of malignancy in biliary neoplasms.

OBJECTIVES: Adenocarcinomas of the biliary tract frequently present diagnostic challenges because of their histologic overlap with benign and preinvasive lesions. The molecular profiles of biliary adenocarcinomas vary by anatomical location. Variations in IDH1/2, common in intrahepatic cholangiocarcinoma, can lead to defective production of 5-hydroxymethylcytosine (5-hmC). Limited ancillary studies are available for biliary adenocarcinomas, and loss of 5-hmC staining could serve as a helpful ancillary diagnostic tool for biliary tract malignancies. METHODS: We evaluated 93 cases-20 benign biliary lesions, 15 preinvasive biliary neoplasms, 46 invasive biliary carcinomas, and 12 pancreatic adenocarcinomas-for 5-hmC staining. Preoperative biopsies from 16 cases of biliary carcinoma were also stained. Sixteen nonneoplastic/reactive bile duct biopsies served as controls. RESULTS: Loss of 5-hmC was seen in 41 of 46 (89.1%) biliary malignancies vs 0 of 20 benign tumors (P < .001), for a sensitivity and specificity of 89.1% and 100%, respectively. Intrahepatic cholangiocarcinoma showed loss of 5-hmC in 11 of 13 (84.6%) cases, similar to the 30 of 33 (90.9%) cases in other biliary adenocarcinomas (P = .61). Similarly, 5-hmC loss was more frequent in distal bile duct adenocarcinomas than in pancreatic ductal adenocarcinomas, at 15 of 17 (88.2%) vs 4 of 12 (33.3%), respectively (P = .0045). There was no difference in the frequency of 5-hmC loss in patients that received neoadjuvant therapy vs those who did not (90.9% vs 88.6%, P > .99). 5-hmC immunohistochemistry in preoperative biopsies was concordant with the resection specimen in 81.3% (13/16) of cases. CONCLUSIONS: Loss of 5-hmC is not unique to intrahepatic cholangiocarcinoma among biliary carcinomas, but is a useful diagnostic marker differentiating malignancies of the biliary tree from benign mimics.

Cancer-related cells and oncosomes in the liquid biopsy of pancreatic cancer patients undergoing surgery.

Pancreatic ductal adenocarcinoma (PDAC) has a five-year survival rate of less than 10% due to its late diagnosis, rapid metastasis, and chemotherapeutic resistance. For a small proportion (10-20%) of early-stage patients however, surgical resection of the pancreatic tumor offers the best chance for survival but the effect of surgery on disease dissemination is unknown. The primary objective of this study was to characterize cellular and acellular blood-based analytes in portal and peripheral blood before pancreatic manipulation, during tumor dissection and immediately after surgical resection to determine the effects of the surgery. This study used the non-enriching third generation High-Definition Single Cell Assay (HDSCA3.0) workflow to investigate heterogeneous circulating rare cell population in the blood. Blood from both sites taken before surgical manipulation of the pancreas had significantly greater incidence of total rare cellular and acellular analytes than normal donor samples. Post-surgery portal and peripheral blood had significantly greater incidence of specific cellular and acellular subtypes compared to the matched pre- and during-surgery samples. Our results reveal that in patients with PDAC liquid biopsy analytes are increased in both the portal and peripheral blood; portal blood contains a higher frequency of analytes than in the peripheral blood; total analytes in the portal and peripheral blood samples were significantly associated with the tumor volume and pathological T stage; and the surgical procedure increased the blood levels of circulating cellular and acellular analytes, but not Epi.CTCs or Mes.CTCs. This study demonstrates liquid biopsy's utility in monitoring patients with PDAC with surgically resectable disease.

Retrospective quantification of clinical abdominal DCE-MRI using pharmacokinetics-informed deep learning: a proof-of-concept study.

Introduction: Dynamic contrast-enhanced (DCE) MRI has important clinical value for early detection, accurate staging, and therapeutic monitoring of cancers. However, conventional multi-phasic abdominal DCE-MRI has limited temporal resolution and provides qualitative or semi-quantitative assessments of tissue vascularity. In this study, the feasibility of retrospectively quantifying multi-phasic abdominal DCE-MRI by using pharmacokinetics-informed deep learning to improve temporal resolution was investigated. Method: Forty-five subjects consisting of healthy controls, pancreatic ductal adenocarcinoma (PDAC), and chronic pancreatitis (CP) were imaged with a 2-s temporal-resolution quantitative DCE sequence, from which 30-s temporal-resolution multi-phasic DCE-MRI was synthesized based on clinical protocol. A pharmacokinetics-informed neural network was trained to improve the temporal resolution of the multi-phasic DCE before the quantification of pharmacokinetic parameters. Through ten-fold cross-validation, the agreement between pharmacokinetic parameters estimated from synthesized multi-phasic DCE after deep learning inference was assessed against reference parameters from the corresponding quantitative DCE-MRI images. The ability of the deep learning estimated parameters to differentiate abnormal from normal tissues was assessed as well. Results: The pharmacokinetic parameters estimated after deep learning have a high level of agreement with the reference values. In the cross-validation, all three pharmacokinetic parameters (transfer constant Ktrans, fractional extravascular extracellular volume ve, and rate constant kep) achieved intraclass correlation coefficient and R2 between 0.84-0.94, and low coefficients of variation (10.1%, 12.3%, and 5.6%, respectively) relative to the reference values. Significant differences were found between healthy pancreas, PDAC tumor and non-tumor, and CP pancreas. Discussion: Retrospective quantification (RoQ) of clinical multi-phasic DCE-MRI is possible by deep learning. This technique has the potential to derive quantitative pharmacokinetic parameters from clinical multi-phasic DCE data for a more objective and precise assessment of cancer.

Rising Incidence of Non-Cardia Gastric Cancer among Young Women in the United States, 2000-2018: A Time-Trend Analysis Using the USCS Database.

INTRODUCTION: Although the global incidence of non-cardia gastric cancer (NCGC) is decreasing, there are limited data on sex-specific incidence in the United States. This study aimed to investigate time trends of NCGC from the SEER database to externally validate findings in a SEER-independent national database, and to further assess trends among subpopulations. METHODS: Age-adjusted incidence rates of NCGC were obtained from the SEER database from 2000 to 2018. We used joinpoint models to calculate average annual percentage change (AAPC) to determine sex-specific trends among older (≥55 years) and younger adults (15-54 years). Using the same methodology, findings were then externally validated using SEER-independent data from the National Program of Cancer Registries (NPCR). Stratified analyses by race, histopathology, and staging at diagnosis were also conducted in younger adults. RESULTS: Overall, there were 169,828 diagnoses of NCGC from both independent databases during the period 2000-2018. In SEER, among those <55 years, incidence increased at a higher rate in women (AAPC = 3.22%, p < 0.01) than men (AAPC = 1.51%, p = 0.03), with non-parallel trends (p = 0.02), while a decreasing trend was seen in both men (AAPC = -2.16%, p < 0.01) and women (AAPC = -1.37%, p < 0.01) of the ≥55 years group. Validation analysis of the SEER-independent NPCR database from 2001 to 2018 showed similar findings. Further stratified analyses showed that incidence is disproportionately increasing in young non-Hispanic White women [AAPC = 2.28%, p < 0.01] while remaining stable in their counterpart men [AAPC = 0.58%, p = 0.24] with non-parallel trends (p = 0.04). This pattern was not observed in other race groups. CONCLUSION: NCGC incidence has been increasing at a greater rate in younger women compared to counterpart men. This disproportionate increase was mainly seen in young non-Hispanic White women. Future studies should investigate the etiologies of these trends.

Increasing Pancreatic Cancer Incidence in Young Women in the United States: A Population-Based Time-Trend Analysis, 2001-2018.

BACKGROUND & AIMS: Previous studies have shown an increasing incidence of pancreatic cancer (PC), especially in younger women; however, this has not been externally validated. In addition, there are limited data about contributing factors to this trend. We report age and sex-specific time-trend analysis of PC age-adjusted incidence rates (aIRs) using the National Program of Cancer Registries database without Surveillance Epidemiology and End Results data. METHODS: PC aIR, mortality rates, annual percentage change, and average annual percentage change (AAPC) were calculated and assessed for parallelism and identicalness. Age-specific analyses were conducted in older (≥55 years) and younger (<55 years) adults. PC incidence based on demographics, tumor characteristics, and mortality were evaluated in younger adults. RESULTS: A total of 454,611 patients were diagnosed with PC between 2001 and 2018 with significantly increasing aIR in women (AAPC = 1.27%) and men (AAPC = 1.14%) without a difference (P = .37). Similar results were seen in older adults. However, in younger adults (53,051 cases; 42.9% women), women experienced a greater increase in aIR than men (AAPCs = 2.36%, P < .001 vs 0.62%, P = 0.62) with nonparallel trends (P < .001) and AAPC difference of 1.74% (P < .001). This AAPC difference appears to be due to rising aIR in Blacks (2.23%; P < .001), adenocarcinoma histopathologic subtype (0.89%; P = .003), and location in the head-of-pancreas (1.64%; P < .001). PC mortality was found to be unchanged in women but decreasing in counterpart men (AAPC difference = 0.54%; P = .001). CONCLUSION: Using nationwide data, covering ≈64.5% of the U.S. population, we externally validate a rapidly increasing aIR of PC in younger women. There was a big separation of the incidence trend between women and men aged 15-34 years between 2001 and 2018 (>200% difference), and it did not show slowing down.

Pancreatic Cancer Incidence Trends by Race, Ethnicity, Age and Sex in the United States: A Population-Based Study, 2000-2018.

BACKGROUND AND AIMS: Pancreatic cancer (PC) incidence is increasing at a greater rate in young women compared to young men. We performed a race- and ethnicity-specific evaluation of incidence trends in subgroups stratified by age and sex to investigate the association of race and ethnicity with these trends. METHODS: Age-adjusted PC incidence rates (IR) from the years 2000 to 2018 were obtained from the SEER 21 database. Non-Hispanic White (White), Non-Hispanic Black (Black) and Hispanic patients were included. Age categories included older (ages ≥ 55) and younger (ages < 55) adults. Time-trends were described as annual percentage change (APC) and average APC (AAPC). RESULTS: Younger White [AAPC difference = 0.73, p = 0.01)], Black [AAPC difference = 1.96, p = 0.01)] and Hispanic [AAPC difference = 1.55, p = 0.011)] women experienced a greater rate of increase in IR compared to their counterpart men. Younger Hispanic women experienced a greater rate of increase in IR compared to younger Black women [AAPC difference = -1.28, p = 0.028)] and younger White women [AAPC difference = -1.35, p = 0.011)]. CONCLUSION: Younger women of all races and ethnicities experienced a greater rate of increase in PC IR compared to their counterpart men; however, younger Hispanic and Black women experienced a disproportionately greater increase. Hispanic women experienced a greater rate of increase in IR compared to younger Black and White women.

Early Application of Next-Generation Sequencing Identifies Pancreatic Mass as Metastasis From an EGFR-Mutated Lung Adenocarcinoma.

Pancreatic metastasis of primary lung adenocarcinoma is a rare occurrence, accounting for <0.3% of all pancreatic malignancies. Given that the prognosis and treatment options for primary pancreatic cancer differ greatly from pancreatic metastases from a primary site, an accurate diagnosis is critical. This report presents a unique case of a 65-year-old man who was admitted with significant unintentional weight loss, fatigue, abdominal pain, and jaundice, and found to have a pancreatic mass initially thought to be primary pancreatic adenocarcinoma and subsequently diagnosed as an EGFR-mutated lung adenocarcinoma with metastases to the pancreas via early application of next-generation sequencing (NGS). The use of NGS early in the patient's clinical course not only changed the treatment strategy but also drastically altered the prognosis. Although metastatic pancreatic adenocarcinoma has a poor prognosis and survival rate, treatment of EGFR-mutated non-small cell lung cancer with EGFR tyrosine kinase inhibitors is associated with high response rates. Importantly, our case demonstrates that timely application of NGS very early in the disease course is paramount to the diagnosis, management, and prognosis of solid malignancies.

Risk prediction of pancreatic cancer using AI analysis of pancreatic subregions in computed tomography images.

Early detection of Pancreatic Ductal Adenocarcinoma (PDAC) is complicated as PDAC remains asymptomatic until cancer advances to late stages when treatment is mostly ineffective. Stratifying the risk of developing PDAC can improve early detection as subsequent screening of high-risk individuals through specialized surveillance systems reduces the chance of misdiagnosis at the initial stage of cancer. Risk stratification is however challenging as PDAC lacks specific predictive biomarkers. Studies reported that the pancreas undergoes local morphological changes in response to underlying biological evolution associated with PDAC development. Accurate identification of these changes can help stratify the risk of PDAC. In this retrospective study, an extensive radiomic analysis of the precancerous pancreatic subregions was performed using abdominal Computed Tomography (CT) scans. The analysis was performed using 324 pancreatic subregions identified in 108 contrast-enhanced abdominal CT scans with equal proportion from healthy control, pre-diagnostic, and diagnostic groups. In a pairwise feature analysis, several textural features were found potentially predictive of PDAC. A machine learning classifier was then trained to perform risk prediction of PDAC by automatically classifying the CT scans into healthy control (low-risk) and pre-diagnostic (high-risk) classes and specifying the subregion(s) likely to develop a tumor. The proposed model was trained on CT scans from multiple phases. Whereas using 42 CT scans from the venous phase, model validation was performed which resulted in ~89.3% classification accuracy on average, with sensitivity and specificity reaching 86% and 93%, respectively, for predicting the development of PDAC (i.e., high-risk). To our knowledge, this is the first model that unveiled microlevel precancerous changes across pancreatic subregions and quantified the risk of developing PDAC. The model demonstrated improved prediction by 3.3% in comparison to the state-of-the-art method that considers the global (whole pancreas) features for PDAC prediction.

Phase I trial of Bermekimab with nanoliposomal irinotecan and 5-fluorouracil/folinic acid in advanced pancreatic ductal adenocarcinoma.

In this phase I dose-escalation trial, we assess the maximum tolerated dose (MTD) of Bermekimab in combination with Nanoliposomal Irinotecan (Nal-Iri) and 5-Fluorouracil/Folinic Acid (5-FU/FA). Secondarily, we investigate effects on weight, lean body mass, quality-of-life, the gut microbiome composition, inflammatory biomarkers, progression-free survival, and overall survival. This was a single-arm, open-label adaptive Bayesian dose-escalation study of Bermekimab combined with Nal-Iri and 5FU/FA in patients with advanced or locally advanced PDAC who failed gemcitabine-based chemotherapy. 22 patients enrolled between 2017 and 2019. 3 of 21 patients experienced dose-limiting toxicities attributable to the chemotherapy backbone. 58% (10/17) of patients exhibited weight stability. Physical performance status was preserved among all subjects. Patients reported improvements in quality-of-life metrics via QLQ-PAN26 questioner (-3.6, p = 0.18) and functional well-being (1.78, p = 0.02). Subjects exhibited a decrease in inflammatory cytokines, notably, vascular endothelial growth factor (-0.86, p = 0.017) with Bermekimab. Bermekimab treatment was associated with an increased abundance of gut health-promoting bacterial genera Akkermansia, with 3.82 Log2-fold change from baseline. In sum, Bermekimab is safe to be used in conjunction with Nal-Iri and 5-FU/FA chemotherapy. This benign toxicological profile warrants further Phase I/II investigation of Bermekimab in combinatorial strategies, and the impact of anti-IL-1α antibodies on the gut microbiome.Clinical trials registration: NCT03207724 05/07/2017.

Segmentation of Pancreatic Subregions in Computed Tomography Images.

The accurate segmentation of pancreatic subregions (head, body, and tail) in CT images provides an opportunity to examine the local morphological and textural changes in the pancreas. Quantifying such changes aids in understanding the spatial heterogeneity of the pancreas and assists in the diagnosis and treatment planning of pancreatic cancer. Manual outlining of pancreatic subregions is tedious, time-consuming, and prone to subjective inconsistency. This paper presents a multistage anatomy-guided framework for accurate and automatic 3D segmentation of pancreatic subregions in CT images. Using the delineated pancreas, two soft-label maps were estimated for subregional segmentation-one by training a fully supervised naïve Bayes model that considers the length and volumetric proportions of each subregional structure based on their anatomical arrangement, and the other by using the conventional deep learning U-Net architecture for 3D segmentation. The U-Net model then estimates the joint probability of the two maps and performs optimal segmentation of subregions. Model performance was assessed using three datasets of contrast-enhanced abdominal CT scans: one public NIH dataset of the healthy pancreas, and two datasets D1 and D2 (one for each of pre-cancerous and cancerous pancreas). The model demonstrated excellent performance during the multifold cross-validation using the NIH dataset, and external validation using D1 and D2. To the best of our knowledge, this is the first automated model for the segmentation of pancreatic subregions in CT images. A dataset consisting of reference anatomical labels for subregions in all images of the NIH dataset is also established.

Chemical Exchange Saturation Transfer for Pancreatic Ductal Adenocarcinoma Evaluation.

OBJECTIVES: The aims of the study are to evaluate the feasibility of using pH-sensitive magnetic resonance imaging, chemical exchange saturation transfer (CEST) in pancreatic imaging and to differentiate pancreatic ductal adenocarcinoma (PDAC) with the nontumor pancreas (upstream and downstream) and normal control pancreas. METHODS: Sixteen CEST images with PDAC and 12 CEST images with normal volunteers were acquired and magnetization transfer ratio with asymmetric analysis were measured in areas of PDAC, upstream, downstream, and normal control pancreas. One-way analysis of variance and receiver operating characteristic curve were used to differentiate tumor from nontumor pancreas. RESULTS: Areas with PDAC showed higher signal intensity than upstream and downstream on CEST images. The mean (standard deviation) values of magnetization transfer ratio with asymmetric analysis were 0.015 (0.034), -0.044 (0.030), -0.019 (0.027), and -0.037 (0.031), respectively, in PDAC area, upstream, downstream, and nontumor area in patient group and -0.008 (0.024) in normal pancreas. Significant differences were found between PDAC and upstream ( P < 0.001), between upstream and normal pancreas ( P = 0.04). Area under curve is 0.857 in differentiating PDAC with nontumor pancreas. CONCLUSIONS: pH-sensitive CEST MRI is feasible in pancreatic imaging and can be used to differentiate PDAC from nontumor pancreas. This provides a novel metabolic imaging method in PDAC.

Comparison of no stent fixation, endoscopic suturing, and a novel over-the-scope clip for stent fixation in preventing migration of fully covered self-expanding metal stents: a retrospective comparative study (with video).

BACKGROUND AND AIMS: Endoscopic suturing and over-the-scope clips (OTSCs) are used to prevent migration of fully covered self-expandable metal stents (FCSEMSs). Recently, a dedicated OTSC was developed for securing FCSEMSs. Our primary aim was to compare the frequency of stent migration without stent fixation versus fixation with suturing or OTSCs, and out secondary aims were to compare clinical success, procedure duration, and adverse events. METHODS: A retrospective cohort study evaluated the outcome of stent placement throughout the entire GI tract from 2013 to 2021. Stent migration was determined as stent displacement ≥2 cm endoscopically or radiographically. Clinical success was defined as resolution of indication at follow-up. RESULTS: Four hundred thirty-three procedures were performed, 239 (55%) without fixation, 140 (32%) with suturing, and 54 (12%) with OTSCs. Stent migration rates were 62% without fixation, 57% with suturing, and 35% with OTSCs (P = .013). The median time to stent migration was 3 weeks without fixation, 5 weeks with suturing, and 6 weeks with OTSCs (P = .023). The clinical success rate was 43%. The median procedure time for OTSCs was shorter compared with suturing (42 vs 68 minutes, P = .002). Adverse event rates trended toward being lowest with OTSCs at 9% compared with 21% without fixation and 18% with suturing (P > .05). CONCLUSIONS: OTSCs for stent fixation were found to have significantly lower migration rates compared with no fixation and suturing. Moreover, OTSCs were associated with decreased overall procedure time and total costs per procedure while trending to be associated with fewer adverse events.

Novel Endoscopic Polypectomy Surveillance Technique for Fundic Gland Polyps in Familial Adenomatous Polyposis Can Improve Early Detection of Dysplasia and Gastric Cancer.

INTRODUCTION: Fundic gland polyps (FGPs) are commonly found in patients with familial adenomatous polyposis (FAP) and are considered benign. Biopsies are not routinely performed, and conventional forceps may be time-consuming and/or yield nonrepresentative histology. The purpose of this study was to evaluate the role of a novel endoscopic polypectomy surveillance (EPS), a large volume cold-snare polypectomy technique of random FGPs, in the incidence of dysplasia and gastric cancer (GC) in FAP. METHODS: This is a retrospective longitudinal cohort of patients with FAP referred to a tertiary care center for duodenal adenoma surveillance and who underwent EPS of FGPs between 2001 and 2019. Demographic, endoscopic, and clinicopathologic information was reviewed. RESULTS: Thirty-five patients with FAP were identified at initial endoscopy by the mean age of 43.4 years (±12.8). One hundred thirteen surveillance endoscopies were performed in total using EPS. Dysplasia of FGPs was present on initial esophagogastroduodenoscopy in 7 patients (20%), and 13 additional patients (46.4%) progressed to low-grade dysplasia. Three patients (15%) who subsequently had progression to GC were found to have signet ring cell cancer within the foci of FGPs through EPS. One patient presented as metastatic GC. Progression from nondysplastic FGP to low-grade dysplasia occurred over 63 months (±46.3) with further progression to GC over 34 months (±8.5). Endoscopic risk factors for cancer were polyps >10 mm in size ( P < 0.001) and carpeting of polyps ( P < 0.001). The 5-year cumulative incidence of developing dysplasia was 35.7%. DISCUSSION: We identified that the incidence of dysplasia and GC is higher than previously reported in patients with FAP. Our study used a novel EPS technique and was able to identify GC within the foci of FGPs. Upper endoscopic guidelines should include a more rigorous sampling method for FGPs, such as EPS, to optimize early detection of dysplasia and GC.

Rio de Janeiro Global Consensus on Landmarks, Definitions, and Classifications in Barrett's Esophagus: World Endoscopy Organization Delphi Study.

BACKGROUND & AIMS: Despite the significant advances made in the diagnosis and treatment of Barrett's esophagus (BE), there is still a need for standardized definitions, appropriate recognition of endoscopic landmarks, and consistent use of classification systems. Current controversies in basic definitions of BE and the relative lack of anatomic knowledge are significant barriers to uniform documentation. We aimed to provide consensus-driven recommendations for uniform reporting and global application. METHODS: The World Endoscopy Organization Barrett's Esophagus Committee appointed leaders to develop an evidence-based Delphi study. A working group of 6 members identified and formulated 23 statements, and 30 internationally recognized experts from 18 countries participated in 3 rounds of voting. We defined consensus as agreement by ≥80% of experts for each statement and used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to assess the quality of evidence and the strength of recommendations. RESULTS: After 3 rounds of voting, experts achieved consensus on 6 endoscopic landmarks (palisade vessels, gastroesophageal junction, squamocolumnar junction, lesion location, extraluminal compressions, and quadrant orientation), 13 definitions (BE, hiatus hernia, squamous islands, columnar islands, Barrett's endoscopic therapy, endoscopic resection, endoscopic ablation, systematic inspection, complete eradication of intestinal metaplasia, complete eradication of dysplasia, residual disease, recurrent disease, and failure of endoscopic therapy), and 4 classification systems (Prague, Los Angeles, Paris, and Barrett's International NBI Group). In round 1, 18 statements (78%) reached consensus, with 12 (67%) receiving strong agreement from more than half of the experts. In round 2, 4 of the remaining statements (80%) reached consensus, with 1 statement receiving strong agreement from 50% of the experts. In the third round, a consensus was reached on the remaining statement. CONCLUSIONS: We developed evidence-based, consensus-driven statements on endoscopic landmarks, definitions, and classifications of BE. These recommendations may facilitate global uniform reporting in BE.

Predicting pancreatic ductal adenocarcinoma using artificial intelligence analysis of pre-diagnostic computed tomography images.

BACKGROUND: Early stage diagnosis of Pancreatic Ductal Adenocarcinoma (PDAC) is challenging due to the lack of specific diagnostic biomarkers. However, stratifying individuals at high risk of PDAC, followed by monitoring their health conditions on regular basis, has the potential to allow diagnosis at early stages. OBJECTIVE: To stratify high risk individuals for PDAC by identifying predictive features in pre-diagnostic abdominal Computed Tomography (CT) scans. METHODS: A set of CT features, potentially predictive of PDAC, was identified in the analysis of 4000 raw radiomic parameters extracted from pancreases in pre-diagnostic scans. The naïve Bayes classifier was then developed for automatic classification of CT scans of the pancreas with high risk for PDAC. A set of 108 retrospective CT scans (36 scans from each healthy control, pre-diagnostic, and diagnostic group) from 72 subjects was used for the study. Model development was performed on 66 multiphase CT scans, whereas external validation was performed on 42 venous-phase CT scans. RESULTS: The system achieved an average classification accuracy of 86% on the external dataset. CONCLUSIONS: Radiomic analysis of abdominal CT scans can unveil, quantify, and interpret micro-level changes in the pre-diagnostic pancreas and can efficiently assist in the stratification of high risk individuals for PDAC.