Gastroenterology elsewhere

SURGICAL OUTCOMES IN OCTOGENARIANS WITH PANCREATIC DUCTAL ADENOCARCINOMA Pande R, Attard JA, Al-Sarireh B. Oncological outcomes after pancreatoduodenectomy for pancreatic ductal adenocarcinoma in octogenarians: A case–control study. BJS Open 2023 Jul 10;7(4):zrad053. Pancreatic ductal adenocarcinoma (PDAC) has poor 5-year survival, even if operated due to local recurrence and distant metastasis. With growing life expectancy, PDAC is becoming common in the elderly. In this article, authors retrospectively compare 110 octogenarians (median age = 81 years) with 110 younger population (median age = 69 years) diagnosed with PDAC. Despite the higher Charlson Comorbidity Index and lesser usage of adjuvant chemotherapy in the octogenarians, the overall survival was similar in both groups (octogenarians median: 20 months vs. younger median: 29 months; P = 0.095). Disease-free survival was also comparable between both groups. Low ECOG (European), low preoperative albumin, and high lymph node ratio were independent predictors of disease-free survival. Frailty and quality of life have not been included in this study. Yet, this article gives valuable insight into the outcomes of performing major abdominal surgery in those above 80 years who are generally considered too weak to withstand the procedure. Age alone should not be a contraindication in an otherwise reasonably fit person with resectable PDAC. WHERE DOES CAPSULE ENDOSCOPY STAND TODAY? Singla N, Inavolu P, Jagtap N. Small-bowel Capsule Endoscopy: Experience from a single large tertiary care center. Endosc Int Open 2023 Jun 29;11(6):E623-E628. doi: 10.1055/a-2096-2453. PMID: 37614640; PMCID: PMC10442921. Small-bowel evaluation has remained a challenge in the past, depending on radiographic images and capsule endoscopy. Enteroscopy has significantly impacted the evaluation of small bowel diseases, allowing tissue sampling and therapy. In this retrospective analysis, of 1154 CE studies, the most common indication for ordering CE was bleeding (68%). Although positive findings like erythematous patches and red spots were seen in 2/3rd of the cases, the causative bleeding site was identified in only 40% of patients. Small bowel study was completed in 90% of patients, and 2% had capsule retention due to an anatomical abnormality. Capsule endoscopy even with its limitations has its place, especially in patients who are unwilling to enteroscopy and unfit. MIRIKIZUMAB – LUCENT-1 AND LUCENT-2 TRIALS D'Haens G, Dubinsky M, Kobayashi T. Mirikizumab as Induction and Maintenance Therapy for Ulcerative Colitis. N Engl J Med. 2023 Jun 29;388(26):2444-2455. doi: 10.1056/NEJMoa2207940. Erratum in: N Engl J Med 2023 Aug 24;389(8):772. PMID: 37379135. Guselkumab and risankizumab are monoclonal antibodies that bind to the p19 subunit of interleukin 23 used in the treatment of Crohn's disease. In this phase III study, mirikizumab, a novel antibody against the p19 subunit, has been evaluated in patients with moderate-to-severe ulcerative colitis. Both induction (LUCENT-1) and maintenance (LUCENT-2) were studied in this 52-week trial. 1162 patients with ulcerative colitis (predominantly moderate) were randomized in a 3:1 ratio to receive mirikizumab 300 mg (n = 868) or placebo (n = 294) intravenously at 0, 4, and 8 weeks. At week 12, clinical remission was seen in 25% of the mirikizumab group (vs. 13%, P < 0.001). The responders were randomized in a 2:1 ratio for maintenance trial to 200 mg mirikizumab (n = 365) and placebo (179) intravenously every 4 weeks for 40 weeks. At 52 weeks, half of the mirikizumab group had achieved clinical remission (vs. 25%, P < 0.001). Secondary endpoints such as endoscopic remission, histologic remission, steroid-free remission, and reduction in urgency were also higher in the mirikizumab group. Flu-like symptoms and arthralgia were higher in the mirikizumab group. Increased frequency of opportunistic infections and cancer were observed in the mirikizumab group. The study shows promising results, and future research may show more data on safety, especially opportunistic infections. REDUCTION IN PORTAL PRESSURES AFTER ENDOSCOPIC SLEEVE GASTROPLASTY Jirapinyo P, Thompson CC, Garcia-Tsao G. Endoscopic gastric plication reduces portosystemic pressure gradient in patients with NAFLD and compensated advanced chronic liver disease. Endoscopy 2023 Aug 2. doi: 10.1055/a-2146-8857. Epub ahead of print. PMID: 37532114. Endoscopic sleeve gastroplasty (ESG) is generally offered to patients with morbid obesity and those who have not achieved the desired weight loss with lifestyle changes. Researchers in this study aim to seek the effect of ESG and the subsequent weight loss on the portal pressure gradient (PPG) in patients with obesity nonalcoholic fatty liver disease/compensated advanced chronic liver disease. Twenty patients with a baseline mean PPG of 5.5 mm of Hg (measured by EUS) underwent ESG. At 6 months, the mean PPG was 1.8 mm of Hg, which is quite impressive. Besides this, the average total weight loss was 13% in comparison to the average weight loss of 4% with lifestyle changes. A promising pilot study and future comparative trials may provide more robust information if this could become a game changer for patients with obesity and liver disease. SURGICAL VERSUS NONSURGICAL MANAGEMENT OF MALIGNANT BOWEL OBSTRUCTION Krouse RS, Anderson GL, Arnold KB. Surgical versus nonsurgical management for patients with malignant bowel obstruction (S1316): A pragmatic comparative effectiveness trial. Lancet Gastroenterol Hepatol 2023 Aug 1:S2468-1253(23) 00191-7. doi: 10.1016/S2468-1253(23)00191-7. Epub ahead of print. PMID: 37541263. Malignant bowel obstruction is an incapacitating situation for patients, preventing them from enjoying a meal and emptying their bowels. Besides these symptoms, nausea, bloating, and vomiting diminish the quality of life. In this pragmatic comparative effectiveness trial, researchers randomize consenting patients (n = 49) to surgery (24) or medical management (25) and also include patient choice-guided management (n = 150, surgery = 58, medical = 92). The number of days alive and out of hospital was considered the primary end point. These 'good days' were calculated up to 91 days from the time of diagnosis. The good days were similar between operated (mean 42.6 days) and nonoperated patients (mean 43.9 days) in the randomized groups. In the patient choice groups, the mean number of days was slightly higher, but similar (surgery 52.7 days vs. medical 54.8 days). The use of the nasogastric tube and the ability to eat were also similar between both groups. Although the randomized group is small, this study offers important insights into the outcome of choosing one therapy over another. Surgery in a patient with advanced malignancy may hasten death. The study also suggests that coercing patients and families to choose one over the other would be unfruitful and should be guided by patient's choices. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.