Roy S. Dwarkasing

Endoscopic retrograde cholangio-pancreatography (ERCP) with plastic stent placement is the standard pertaining preoperative biliary drainage for resectable perihilar cholangiocarcinoma (pCCA). Uncovered self-expanding metal stents (ucSEMS) have shown better outcomes in palliative settings. This pilot study aimed to assess the feasibility and safety of direct ucSEMS placement via ERCP for resectable pCCA. In this single-centre pilot study, ten patients with presumed resectable pCCA (without prior drainage) underwent ERCP aiming to place an ucSEMS directly across the papilla into the future liver remnant (FLR). If the opposing liver segment was cannulated or had contrast injected, a stent was placed here too. Primary outcome was feasibility, defined as ucSEMS placement in the targeted liver segment without the need for additional drainage, with adequate bilirubin decrease according to the TOKYO criteria. Secondary outcomes included ERCP adverse events (AE) and successful stent removal during surgery. In 5 of the 10 included patients, direct ucSEMS placement in the FLR was technically successful, but one required additional intervention, resulting in 40% feasibility. All patients experienced ERCP-AE (five mild, five severe). Only two patients underwent hepatectomy, one after unsuccessful ERCP and one with successful ucSEMS removal during hepatectomy. Other patients did not proceed to hepatectomy due to ERCP-related AE (n = 3), disease progression (n = 2), or unresectability upon staging (n = 3). Direct placement of ucSEMS for resectable pCCA showed limited feasibility and high AE rates. Its routine use is not justified without further refinement and larger studies to reduce AE and improve outcomes.

Lymph node (LN) involvement is a negative prognostic factor for patients with distal cholangiocarcinoma (dCCA). Therefore, preoperative assessment of the LN status could potentially aid therapy decision making. Endoscopic ultrasound (EUS) is often used to obtain a tissue diagnosis of the primary tumor, but can also be used to sample suspicious LN. The aim of this study was to evaluate the impact of EUS for suspicious LN in patients with presumed resectable dCCA. In this multicenter cohort study, patients with potentially resectable dCCA who underwent preoperative EUS between 2010 and 2020 were retrospectively included. Impact of EUS was defined as the percentage of patients who were precluded from surgical exploration due to pathologically confirmed LN metastasis found with EUS tissue acquisition (EUS-TA). A total of 149 patients were included. In the 187 EUS procedures performed, a total of 58 LN among 43 patients were described. Among five patients (3.6%), EUS-TA of LN confirmed malignancy in six of the 20 LN (30%). In four patients (2.7%), surgical exploration was withheld due to nodal involvement (extraregional in two, regional in two). Finally, 109 patients (73.2%) underwent surgical exploration. During exploration or at surgical pathology specimens, malignant regional LN was identified in 58 patients (53.2%). Preoperative EUS had a limited but clinically important yield for nodal staging in patient with presumed resectable dCCA but was not executed in systematic fashion. Further prospective studies should investigate whether systematic nodal staging with EUS could improve preoperative decision making.

Transanal advancement flap repair (TAFR) fails in approximately 30–40% of patients with a cryptoglandular transsphincteric fistula. An additional intraoperative injection of autologous platelet-rich stroma (PRS) with TAFR proved to be safe, feasible, and effective in the short term for the treatment of cryptoglandular transsphincteric fistula in a tertiary referral center. In this study, we assessed the long-term outcomes in patients with a cryptoglandular transsphincteric fistula who were treated with an additional intraoperative autologous PRS injection with TAFR (n = 43). The majority of the patients (88%) had a complex transsphincteric fistula (high transsphincteric and/or multiple side tracts) and underwent (one or more) fistula procedure(s) aimed at fistula repair (56%) before study inclusion. At a median follow-up time of 4.2 years [IQR 3.5–5.1], long-term primary clinical closure (i.e., clinical closure of the treated external fistula opening(s) after TAFR with additional PRS injection without the need for any re-interventions during long-term follow-up) was observed in 77% of the patients. Subsequently, 94% of these patients also reached radiological healing (i.e., fibrotic fistula tract on MRI). Recurrence after clinical closure or radiological healing was observed in 9% and 5%. Unplanned re-interventions were performed in 12% of the patients for recurrent or residual fistulizing disease. In this uncontrolled pilot study, additional autologous PRS injection with TAFR showed promising outcomes, as long-term primary clinical closure and, subsequently, radiological healing was reached in the vast majority of tertiary referral patients with a (complex) cryptoglandular transsphincteric fistula at long-term follow-up. In addition, recurrence rates were low. Future randomized research is warranted to study the effects of PRS.

Perianal fistulizing disease, commonly associated with Crohn’s disease, poses significant diagnostic and therapeutic challenges due to its complex anatomy and high recurrence rates. Radiological imaging plays a pivotal role in the accurate diagnosis, classification, and management of this condition. This article reviews the current radiological modalities employed in the evaluation of perianal fistulizing disease, including magnetic resonance imaging (MRI), endoanal ultrasound, and computed tomography (CT). MRI, recognized as the gold standard, offers superior soft tissue contrast and multiplanar capabilities, facilitating detailed assessment of fistula tracts and associated abscesses. CT, although less detailed than MRI, remains valuable in acute settings for detecting abscesses and guiding drainage procedures. This article discusses the advantages and limitations of each modality, highlights the importance of standardized imaging protocols, and underscores the need for interdisciplinary collaboration in the management of perianal fistulizing disease. Future directions include advancements in imaging techniques and the integration of artificial intelligence to enhance diagnostic accuracy and treatment outcomes.

Purpose: Recently introduced hybrid 2-[18 F]-fluoro-2-deoxy-D-glucose (18 F-FDG) Positron Emission Tomography (PET) combined with Magnetic Resonance Imaging (MRI) may aid in proper diagnosis and staging of perihilar cholangiocarcinoma (pCCA). The aim of this study is to assess the effect of 18 F-FDG PET/MRI on diagnosis and clinical decision making in the pre-operative work up of pCCA. Methods: In this single-centre pilot study patients with presumed resectable pCCA underwent state-of-the-art 18 F-FDG hybrid PET/MRI using digital silicone photomultiplier detectors integrated within a 3-Tesla bore. Data were collected on several baseline and imaging characteristics. The primary outcome measure was the added diagnostic information and the effect on clinical decision making. Secondary aim was to correlate quantitative PET signal intensity to patient- and tumour characteristics. High and low SUVmax subgroups related to the mean value were made. Significance of lesion- and patient characteristics with the high and low SUVmax subgroups, as well as TLR and TBR, was evaluated with Fisher’s exact test or Mann-Whitney-U test. Results: In total 14 patients were included (mean age 62.4 years, 64% male). Final diagnosis was pCCA in 10 patients (71.4%), follicular lymphoma in one patient (7.1%) and benign disease in the remaining three patients. FDG-PET/MRI added valuable diagnostic information in six (43%) patients and affected clinical decision making in two of these patients (14%) by increasing confidence for malignancy which lead to the decision for surgery on short term. High SUVmax values were seen in half of cases with pCCA and half of cases with non-cancerous lesions. In addition, high SUVmax values were directly associated with primary sclerosing cholangitis when present (p = 0.03). Conclusion: Simultaneous 18 F-FDG-PET/MRI added diagnostic information in six of fourteen patients and influenced clinical decision making in two patients (14%) with presumed resectable pCCA.

Background and study aims Lymph node (LN) involvement is a poor prognostic factor for patients with intrahepatic cholangiocarcinoma (iCCA). The aim of this study was to evaluate the yield and impact on clinical decision making of endoscopic ultrasound with tissue acquisition (EUS-TA) of LNs in patients with potentially resectable iCCA. Patients and methods In this multicenter cohort study, patients with potentially resectable iCCA and preoperative EUS between 2010 and 2020 were retrospectively included. The impact of EUS-TA was defined as the percentage of patients who did not undergo surgical exploration due to pathologically confirmed positive LNs found with EUS-TA. Results A total of 56 patients underwent EUS, with 91% of patients to target suspicious LNs on imaging. EUS-TA of LNs confirmed malignancy in 21 LNs among 19 patients (34%). In 17 patients (30%), surgical exploration was withheld due to nodal involvement. Finally, 24 patients (43%) underwent surgical exploration among whom positive regional LNs were identified in six patients (25%). Conclusions In patients with potentially resectable iCCA and suspicious LNs on cross-sectional imaging, EUS-TA confirmed LN involvement in 30% of patients. Surgical exploration was withheld mostly because of extraregional LN involvement and regional LN involvement in patients with high surgical risk.