Rungsun Rerknimitr

Background Hypoxemia affects up to 23% of patients undergoing ERCP under nurse-administered propofol sedation (NAPS) with a standard nasal cannula (SNC). High-flow nasal cannula (HFNC) provides heated, humidified oxygen at high gas flow with more controlled inspired oxygen delivery than conventional low-flow oxygen and may reduce hypoxemic events during sedation. We compared HFNC with SNC during ERCP under NAPS. Methods In this two-center, prospective, randomized trial, 300 adults undergoing ERCP between October 2025 and June 2026 were allocated 1:1 to HFNC (flow 50 L/min; FiO₂ 0.50) or SNC (5 L/min). All procedures were performed in the prone position under propofol-based NAPS. The primary outcome was hypoxemia (SpO₂ < 92% for > 10 s). Secondary outcomes included airway interventions and cardiovascular events. Results Baseline characteristics, procedural factors, and sedation dosages were comparable. Hypoxemia occurred in 2 of 150 patients (1.3%) with HFNC versus 21 of 150 (14.0%) with SNC (RR 0.10, 95% CI 0.02–0.36; P < 0.001). Jaw-thrust maneuvers (1.3 vs. 12.0%; P < 0.001) and nasopharyngeal airway insertion (0 vs. 9.3%; P < 0.001) were also less frequent with HFNC. No patient required emergency intubation. Hypotension was more frequent with HFNC (16.7 vs. 8.0%; P = 0.02), but no episode required vasopressors or procedure termination. In post hoc analyses, HFNC reduced hypoxemic events in both BMI subgroups; however, the treatment-by-BMI interaction was not significant (P for interaction = 0.65). Conclusions HFNC oxygenation strategy reduced hypoxemic events and rescue airway interventions during ERCP under NAPS, although transient hypotension occurred more frequently. No significant treatment-by-BMI interaction was observed. Trial registry Thai Clinical Trials Registry, TCTR20250901001. Graphical abstract

A 59-year-old Thai woman presented with jaundice and massive hematemesis complicated by cardiac arrest. Emergency endoscopy revealed isolated gastric varices type 1, successfully treated with cyanoacrylate injection. Axial imaging demonstrated diffuse pancreatic enlargement with splenic vein compression and distal common bile duct obstruction. Endoscopic retrograde cholangiopancreatography with biliary stenting was performed. Endoscopic ultrasound (EUS) showed diffuse mixed-echogenic pancreatic infiltration, and EUS-guided biopsy revealed dense lymphoplasmacytic infiltration with 20 immunoglobulin G4-positive plasma cells per high-power field. Elevated serum immunoglobulin G4 (405 mg/dL) also confirmed type 1 autoimmune pancreatitis. Prednisolone therapy resulted in complete clinical and radiologic resolution at 6-week follow-up.

Artificial intelligence in endoscopic ultrasound for lymph node diagnosis: perspective on an evolving frontier

Introduction: The over‐the‐scope clip (OTSC) system is an endoscopic device for treatment of acute nonvariceal upper gastrointestinal bleeding (NVUGIB). It is often used as salvage treatment in cases of failure of standard endoscopic treatment. It is unclear whether OTSC is superior to standard endoscopic treatment as first‐line treatment for acute NVUGIB, in terms of rebleeding and mortality. The objective of this meta‐analysis is to compare the efficacy and safety of OTSC versus standard endoscopic treatment as first‐line treatment for acute nonvariceal upper gastrointestinal bleeding.Methods: Following a PROSPERO‐registered protocol, three blinded reviewers performed a systematic review for studies that compared the use of OTSC with standard endoscopic treatment as first‐line treatment for acute NVUGIB from inception to October 2024. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. A meta‐analysis was conducted in risk ratios and the mean difference.Results: From 14 studies of which five were RCTs (7211 patients), OTSC was associated with significantly lower rates of 30‐day rebleeding (RR: 0.44, 95% CI: 0.32 to 0.61, p < 0.01, I² = 0%), 7‐day rebleeding (RR: 0.50, 95% CI: 0.35 to 0.71, p < 0.01, I² = 0%), and 30‐day mortality (RR: 0.47, 95% CI: 0.33 to 0.67, p = 0.01, I² = 0%) compared with standard endoscopic treatment. OTSC was also associated with significantly higher overall clinical success rates (RR: 1.16, 95% CI: 1.09 to 1.24, p < 0.01, I² = 0%) and significantly lower procedural time (MD: −6.80, 95% CI: −12.53 to −1.07, p = 0.02, I² = 81%) compared with standard endoscopic treatment.Conclusions: OTSC may represent a safe and effective alternative to standard endoscopic treatment for acute NVUGIB. Further large, randomized trials are warranted to confirm these findings.

In the above-mentioned article Figure 3 has been corrected. Correct is for “Stage II” that 3 patients underwent chemotherapy. This was corrected in the online version on April 3, 2025. Article published online: 03 April 2025 © 2025. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

The detection of portal venous circulating tumor cells (CTCs) may better reflect vascular metastasis and predict micrometastasis risk than peripheral blood in patients with pancreatic ductal adenocarcinoma (PDAC). We hypothesize that portal CTCs could better represent micrometastasis and can predict survival in PDAC patients.A single-center, prospective cohort study of patients with stage I–III PDAC was conducted. Portal venous blood was obtained via endoscopic ultrasound-guided sampling, and peripheral blood was collected on the same day. CTCs were detected using EpCAM and mucin1 antibodies and reported as cells/8 mL of blood.Among 35 patients, the portal and peripheral CTC detection rates were 94.3% and 82.9%, respectively. Advanced PDAC with locoregional metastasis had higher portal CTCs than less aggressive disease (P < 0.05), while peripheral CTCs showed no significant differences. During the 50-month follow-up, patients with portal CTCs ≥8 had poorer survival (6.1 vs. 19.0 months; P = 0.001) and patients with peripheral CTCs ≥3 also had poorer survival (4.6 vs. 14.2 months; P = 0.002). In multivariable analysis, both portal CTCs ≥8 and peripheral CTCs ≥3 showed significant adjusted associations with survival (adjusted hazard ratio 3.4 [P = 0.009] and 2.7 [P = 0.02], respectively).Higher CTC counts in both the portal and peripheral systems were significantly associated with poorer survival in stage I–III PDAC; however, only portal CTCs reflected tumor aggression and locoregional metastasis.

I read with great interest the article by Gurav et al. that retrospectively analyzed and identified independent predictors of persistent pain in patients with chronic calcific pancreatitis who underwent extracorporeal shockwave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) for stone clearance [1]. In their treatment protocol, the authors routinely performed ERCP for stone fragment clearance within a few days after ESWL. Although, they excluded those with multiple pancreatic duct strictures from the study, they still found 14.5% (n = 93) of patients with pancreatic duct strictures. The study highlights the need for further investigation into stricture management within this subgroup, particularly regarding the success of endoscopic treatment and its impact on pain persistence. This is especially relevant because the study analysis identified pancreatic duct strictures as a predictor of persistent pain even after successful ESWL. In the discussion, the authors cited a key randomized controlled trial (RCT) comparing pain control with ESWL alone versus ESWL with ERCP with/without stenting [2]. Unfortunately, this RCT only placed stents in 45% of the endoscopy group and ultimately concluded that endoscopic therapy added cost without additional pain control benefit. However, further analysis of the Gurav et al. data could be particularly enlightening. If successful pain control could be demonstrated in patients with resolved strictures after endoscopic therapy, it would challenge the notion that ERCP may be necessary in certain patients with pancreatic duct strictures following ESWL. In my opinion, endoscopic therapy should be attempted in those with only a few strictures located at the head and neck of the pancreas and in those with pancreas divisum [3]. Received: 22 June 2024 Accepted: 28 June 2024 Article published online: 28 January 2025 © 2025. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany