Annals of Gastroenterology

Hellenic Association for the Study of the Liver (HASL): revised clinical practice guidelines for autoimmune hepatitis

2024-11-21T08:57:12+02:00

Autoimmune hepatitis (AIH) is a rare liver disease, of unknown origin, characterized by considerable heterogeneity. AIH can affect both sexes, of all ages, ethnicities and races. The revised Clinical Practice Guidelines (CPGs) of the Hellenic Association for the Study of the Liver aim to provide updated guidance to clinicians. The diagnosis of AIH is based on clinicopathological characteristics, such as elevation of immunoglobulin G (IgG) levels, detection of autoantibodies, portal or lobular hepatitis at the histological level, absence of viral hepatitis markers, and a favorable response to immunosuppressive treatment. Clinical manifestations at onset vary, from no symptoms to the fulminant form of the disease. Aminotransferases and bilirubin levels also vary, while liver biopsy is a prerequisite to establish a firm diagnosis. Investigation for detection of autoantibodies is the cornerstone for diagnosis, if it is performed according to the CPGs. Treatment of AIH should aim towards the achievement of complete biochemical response (CBR; normalization of aminotransferases and IgG) no later than 6-12 months after treatment initiation, and also histological remission of the disease. All patients with active disease, irrespective of the presence of cirrhosis, should receive personalized and response-guided first-line induction treatment with predniso(lo)ne combined with mycophenolate mofetil or azathioprine. Treatment should be given for at least 3-5 years, and for at least 2 years after the achievement of CBR, while liver biopsy should be considered before treatment cessation. The updated CPGs also provide guidance for the management of difficult-to-treat patients, including those with variants and specific forms of AIH. Keywords Autoimmune hepatitis, clinical practice guidelines, corticosteroids, azathioprine, mycophenolate mofetil

Ann Gastroenterol 2024; 37 (6): 623-654

Laparoscopic Heller myotomy versus peroral endoscopic myotomy in children with esophageal achalasia: a systematic review and meta-analysis

2024-11-21T08:57:12+02:00

Background Currently, laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM) are the best treatment modalities for esophageal achalasia in children. The purpose of this systematic review and meta-analysis is to compare the efficacy of LHM and POEM.

Methods A systematic literature search was performed in PubMed/Medline, Google Scholar and Web of Science for original articles comparing LHM and POEM. All articles were analyzed with respect to operation duration, length of hospital stay, pre- and postoperative Eckardt score (ES), and pre- and postoperative lower esophageal sphincter (LES) pressure.

Results A total of 32 articles, reporting on 800 children, were selected and reviewed. Because of missing diagnostic values of ES and LES in the LHM group, the meta-analysis was limited to the POEM results. According to the random-effects model, the mean ES difference between pre- and post-operation was 4.387 (95% confidence interval [CI] 3.799-4.974), significantly different to zero (z=14.64, P<0.001), while the mean LES pressure difference was 3.63 mmHg mmHg (95%CI 2247-3.879), significantly different to zero (z=7.36, P<0.001). Operation duration was 130.15 min (95%CI 62.59-197.71) for the LHM method and 83.64 min (95%CI 55.14-112.14) for POEM. The pooled estimate of length of hospital stay was 3.4 days (95%CI 2.6-4.44) and it was comparable between the 2 methods.

Conclusions POEM has positive outcomes regarding ES and LES pressure pre- and postoperatively, as well as operation duration, while the length of hospitalization was comparable between POEM and LHM. Well-designed studies are warranted to further clarify differences between the 2 methods.

Keywords Lower esophageal sphincter pressure, operation time, outcome, length of hospitalization, Eckardt score

Ann Gastroenterol 2024; 37 (6): 655-664

Use of artificial intelligence for the detection of Helicobacter pylori infection from upper gastrointestinal endoscopy images: an updated systematic review and meta-analysis

2024-11-21T08:57:13+02:00

Background Helicobacter pylori (H. pylori) infection is associated with various gastrointestinal diseases and may lead to gastric cancer. Currently, endoscopy is the gold standard modality used for diagnosing H. pylori infection, but it lacks objective indicators and requires expert interpretation. In the past few years, the use of artificial intelligence (AI) for diagnosing gastrointestinal pathologies has increased tremendously and may improve the diagnostic accuracy of endoscopy for H. pylori infection. This study aimed to evaluate the diagnostic accuracy of AI algorithms for detecting H. pylori infection using endoscopic images.

Methods Three investigators searched the PubMed, CINHAL and Cochrane databases for studies that compared AI algorithms with endoscopic histopathology for diagnosing H. pylori infection using endoscopic images. We assessed the methodological quality of studies using the QUADAS-2 tool and performed a meta-analysis to estimate the pooled sensitivity, specificity, and accuracy of AI for detecting H. pylori infection.

Results A total of 11 studies were identified that met our inclusion criteria. All were conducted in different countries based in Asia. Our meta-analysis showed that AI had high sensitivity (0.93, 95% confidence interval [CI] 0.90-0.95), specificity (0.92, 95%CI 0.89-0.94), and accuracy (0.92, 95%CI 0.90-0.94) for detecting H. pylori infection using endoscopic images. However, there was also high heterogeneity among the studies (Tau2=0.87, I2=76.10% for generalized effect size; Tau2=1.53, I2=80.72% for sensitivity; Tau2=0.57, I2=70.86% for specificity).

Conclusion This systematic review and meta-analysis showed that AI had high diagnostic accuracy for detecting H. pylori infection using endoscopic images.

Keywords Artificial intelligence, deep learning, machine learning, Helicobacter pylori, endoscopy

Ann Gastroenterol 2024; 37 (6): 665-673

Infliximab trough levels among patients with inflammatory bowel disease in correlation with infliximab treatment escalation: a cross-sectional study from a Greek tertiary center

2024-11-21T08:57:13+02:00

Background Infliximab monitoring correlates with improved outcomes in inflammatory bowel disease (IBD). We aimed to evaluate the association between serum infliximab trough levels (TLs) and therapeutic outcomes in Greek patients with Crohn’s disease (CD) or ulcerative colitis (UC).

Methods This cross-sectional study included consecutive adult patients with IBD receiving intravenous infliximab maintenance therapy at a Greek tertiary center. Therapeutic outcomes assessed were clinical remission (CR), steroid-free clinical remission (SFCR), biochemical remission (BR: C-reactive protein <5 mg/L), and combined (steroid-free and biochemical) remission (SFCBR).

Results Seventy-seven patients participated (62.3% with CD, 16.8% on concomitant immunomodulators), with a mean infliximab infusion duration of 5.1±4.6 years. Forty-seven (61%) patients underwent treatment escalation. Infliximab mean TLs were 7.2±4.9 μg/mL, correlating only with treatment escalation (9.7 vs. 3.6 μg/mL, P<0.001). CR was achieved in 88.3% of patients, SFCR in 80.5%, BR in 62.3%, and SFCBR in 55.8%. In a subgroup analysis, for patients without treatment escalation, higher mean TLs were significantly associated with BR (4.2 vs. 0.8
μg/mL, P=0.020) and SFCBR (4.3 vs. 1.5 μg/mL, P=0.035). In receiver operating characteristic analysis, TLs predicted SFCBR (P=0.016) with good accuracy (area under the curve [AUC] 0.768, 95% confidence interval [CI] 0.584-0.952), with an optimal TL cutoff at 3.4 μg/mL. For patients with treatment escalation, TLs predicted SFCBR (P=0.018) with fair accuracy (AUC 0.653, 95%CI 0.527-0.755), with an optimal TL cutoff at 11 μg/mL.

Conclusions Infliximab TLs correlate with treatment escalation. Higher infliximab TLs may predict combined remission among patients with treatment escalation.

Keywords Inflammatory bowel disease, infliximab monitoring, infliximab trough levels, treatment intensification, treatment escalation

Ann Gastroenterol 2024; 37 (6): 674-681

Endoscopic dilation of small-intestine strictures in Crohn’s disease by balloon-assisted enteroscopy: a systematic review and meta-analysis

2024-11-21T08:57:13+02:00

Background Balloon-assisted enteroscopy (BAE) (both single- and double-balloon enteroscopy) has garnered attention in the treatment of small intestine strictures in patients with Crohn’s disease (CD). This study aimed to evaluate the pooled clinical outcomes of BAE-mediated endoscopic dilation of small intestine strictures in patients with CD.

Methods We searched multiple databases for articles reporting outcomes following BAE for small intestinal strictures in patients with CD. Outcomes studied were pooled technical success, clinical success and adverse events. Standard meta-analysis methods were employed using the randomeffects model, and heterogeneity was studied using I2 statistics.

Results We analyzed 26 studies, 9 prospective and 17 retrospective, involving 1570 patients. The pooled technical success rate of double-balloon enteroscopy was 87.6% (95% confidence interval [CI] 82.1-91.5; I2=53%) and the pooled therapeutic success rate was 69.7% (95%CI 61.6-76.7; I2=71%). The pooled major complications per procedure were 5.5% (95%CI 3.5-8.4; I2=57%); the risk of bleeding was 2.5% (95%CI 1.4-4.2; I2=28%), and the risk of perforation was 2.7% (95%CI 1.6-4.5; I2=3%). The pooled rate of recurrence after the first dilation was 42.3% (95%CI 16.9-72.5; I2=59%), and the rate of repeat endoscopic balloon dilation was 23.9% (95%CI 14.1%-37.5%; I2=85%), while the pooled rate of repeat surgery was 25.3% (95%CI 11.8%-46.0%; I2=44%].

Conclusion BAE is a good first line approach for patients with CD-induced strictures in an attempt to treat symptoms and potentially avoid surgery.

Keywords Crohn’s disease, endoscopic dilation, balloon-assisted enteroscopy, stricture

Ann Gastroenterol 2024; 37 (6): 682-694

Are biopsies from endoscopically normal terminal ileum necessary?

2024-11-21T08:57:13+02:00

Background The terminal ileum is typically examined during colonoscopies, especially in patients with inflammatory bowel disease (IBD) and diarrhea. The yield from performing biopsies of endoscopically normal appearing terminal ileum is less clear, and may be associated with greater costs, healthcare utilization and risk. We aimed to determine whether the biopsy results from endoscopically normal terminal ileum affect clinical management.

Methods This was a retrospective chart review of patients who underwent an ileocolonoscopy with terminal ileum biopsy at a multisite tertiary healthcare system. Patients with a diagnosis of IBD, prior ileocecal resection, or endoscopically abnormal appearing terminal ileum were excluded. Clinical and laboratory data were obtained from the electronic medical record. Comparison between patients was performed using Pearson’s chi-square test.

Results A total of 1018 consecutive patients were identified. Of the 299 who met the inclusion criteria, the majority were female (62.0%) and white (94.7%). Nearly 40% of the patients had a body mass index of 30 kg/m2 or above (38.1%). Terminal ileum biopsies were abnormal in 13 patients (4.3%): 5 patients had chronic ileitis, 6 had acute ileitis, 1 had acute and chronic ileitis, and 1 had amyloid deposition. All patients with either chronic or acute ileitis had chronic diarrhea listed as an indication for their colonoscopy.

Conclusions In patients with a normal appearing terminal ileum, clinically significant histologic abnormalities on biopsies were found in a very small percentage. Based on our findings, the routine biopsy of endoscopically normal appearing terminal ileum has limited diagnostic and therapeutic utility.

Keywords Terminal ileum, routine biopsy, endoscopy, ileitis, inflammatory bowel disease

Ann Gastroenterol 2024; 37 (6): 695-698

Real-world outcomes of collaborative surgery for gastrointestinal tumors by endoscopists and surgeons: a single-center retrospective analysis of 131 patients

2024-11-21T08:57:14+02:00

Background Collaborative surgery by both endoscopists and surgeons is considered effective for providing less invasive local resection of gastrointestinal tumors, to offset the limitations of either pure endoscopic treatments or surgical intervention. The clinical outcomes of collaborative surgery were evaluated to investigate the feasibility and safety of this approach.

Methods In this single-center retrospective observational study, we collected data from consecutive patients who underwent collaborative surgery for lesions located from the laryngopharynx to the anus. The completeness of collaboration, technical success, procedure time, postoperative hospitalization period, and occurrence of adverse events were analyzed.

Results Collaboration surgery was performed for 134 lesions (33 laryngopharyngeal, 2 esophageal, 89 gastric, 8 duodenal and 2 recto-anal) in 131 patients. Collaboration completeness was achieved in 129 lesions (96%). En bloc resection and pathological R0 resection of lesions were achieved in 127 (95%) and 124 (93%) lesions, respectively. The mean procedure time was 188 min. The mean time of discharge was the 11th postoperative day. Five patients (4%) developed relevant postoperative adverse events.

Conclusions These results indicate that collaborative surgery by endoscopists and surgeons was feasible and safe, and may contribute to providing less invasive treatment than conventional surgery. Collaborative surgery is worth considering as a flexible and reliable surgical option, when cooperation may outperform either treatment alone.

Keywords Collaborative surgery, endoscopic full-thickness resection, endoscopic laryngopharyngeal surgery, endoscopic submucosal dissection, laparoscopic and endoscopic cooperative surgery

Ann Gastroenterol 2024; 37 (6): 699-707

Efficacy of atezolizumab–bevacizumab combination therapy early after recurrence of hepatocellular carcinoma following resection or ablation with a curative intent

2024-11-21T08:57:14+02:00

Background The pattern of hepatocellular carcinoma (HCC) recurrence after resection/ablation is intrahepatic and/or systemic. The efficacy of atezolizumab–bevacizumab treatment as early therapy after recurrence has not been extensively evaluated.

Methods We evaluated 32 patients (group A) with early HCC recurrence after resection/ablation and 24 patients (group B) initially diagnosed as Barcelona Clinic Liver Cancer (BCLC)-C, all treated with atezolizumab–bevacizumab. Group A was subdivided in group A1 (progression to BCLC-C, n=14) and group A2 (progression to BCLC-B, n=18).

Results Groups A1/A2 were comparable for all baseline parameters. Objective response was observed in 14.3% and 33.3% of patients in groups A1 and A2, respectively. Median overall survival (OS) was impressive and comparable between the 2 groups (22 and 26 months, respectively, P=0.71), as was median progression-free survival (PFS) (15 and 6 months, respectively, P=0.126). Patients categorized in the advanced stage (groups A1/B) were comparable for all baseline characteristics. Median OS was significantly higher in group A1 compared to B (26 vs. 6 months, P<0.001), as was median PFS (6 vs. 3 months, P=0.086).

Conclusions Early initiation of atezolizumab–bevacizumab after recurrence following curative therapy results in impressive survival rates, irrespective of recurrence pattern. Survival of atezolizumab–bevacizumab treated patients who were initially diagnosed in the BCLC-C stage is significantly different from those who recurred to BCLC-C following potentially curative therapies.

Keywords Hepatocellular carcinoma, recurrence, resection, ablation, atezolizumab–bevacizumab

Ann Gastroenterol 2024; 37 (6): 708-717

Clinical evolution of gallstones following percutaneous cholecystostomy in patients with severe acute calculous cholecystitis: a single-center analysis of 102 cases

2024-11-21T08:57:14+02:00

Background Percutaneous cholecystostomy (PC) is effective in controlling sepsis in patients with severe acute calculous cholecystitis (ACC). The long-term treatment of this group is still debated. We aimed to assess the clinical evolution of gallstones after severe ACC and the outcomes of laparoscopic cholecystectomy (LC) and conservative management, following PC.

Methods This was a retrospective analysis of the rate of readmissions due to recurrent biliary disease and all-cause mortality in subjects who underwent a PC for severe ACC. We compared results between patients who underwent interval LC and those who received conservative management. Readmissions and late mortality were assessed using the Kaplan-Meier method and multivariate regression analysis.

Results A total of 102 patients were included, of whom 30 underwent interval LC and 72 PC only. Overall, 51.6% were readmitted with recurrent biliary events and the rate did not differ between groups (P=0.583). The probability of recurrent gallstone events was higher in the first 30 weeks after PC; in the surgical cohort, 77.8% of them developed before LC. Late deaths occurred in 46.2% of patients: 13.3% LC vs. 61.9% conservative (P<0.001). Three years after PC, the estimated survival was 75% LC vs. 38% conservative (P=0.014). High-grade comorbidities and severity of ACC were positive predictors of all-cause mortality (P=0.004 and P=0.027), whereas LC was a negative predictor (P=0.003).

Conclusions Recurrent biliary events were common following PC for ACC. Interval LC was associated with lower rates of readmissions and all-cause late mortality.

Keywords Calculous cholecystitis, cholecystostomy, laparoscopic cholecystectomy

Ann Gastroenterol 2024; 37 (6): 718-725

Technical success and adverse event rates after endoscopic retrograde cholangiopancreatography using deep sedation with propofol

2024-11-21T08:57:14+02:00

Background With the increasing complexity and prolonged duration of endoscopic retrograde cholangiopancreatography (ERCP) procedures, sedation shifted from conscious sedation with benzodiazepines to deep sedation with propofol. We assessed the technical success and adverse event rates of ERCP with deep versus conscious sedation.

Methods Consecutive patients treated with ERCP in the University Medical Center Utrecht over a 7-year period (2010-2016) were screened for eligibility. Gastroenterologist-administered conscious sedation with midazolam was used from 2010-2013, whilst anesthesiology-administered deep sedation with propofol was used from 2013-2016. Data were retrospectively collected from electronic medical records. Outcomes were technical success and procedure-related adverse events within 30 days after ERCP. Associations of sedation type with outcomes were analyzed in univariable and multivariable analyses.

Results A total of 725 patients were included: 336 (46%) with conscious sedation and 389 (54%) with deep sedation. Technical success was significantly higher when propofol-based sedation was used (317 [82%] vs. 252 [75%], P=0.034). Adverse events also occurred significantly more often in the propofol group (77 [20%] vs. 38 [11%], P=0.002), due to higher rates of post-ERCP cholangitis (21 [5%] vs. 8 [2%], P=0.039), and post-ERCP pancreatitis (29 [7%] vs. 11 [3%], P=0.014). After adjustment, propofol-based sedation remained significantly associated with technical success and adverse events, with odds ratios of 1.53 (95% confidence interval [CI] 1.05-2.21) and 1.95 (95% CI 1.25-3.04), respectively.

Conclusion Propofol-based sedation resulted significantly more often in technical success of ERCP compared with midazolam-based sedation, but adverse events were almost twice as common, with higher rates of post-ERCP pancreatitis and cholangitis.

Keywords Endoscopic retrograde cholangiopancreatography, conscious sedation, deep sedation, biliary drainage, adverse events

Ann Gastroenterol 2024; 37 (6): 726-733

Cytokine signatures in post-endoscopic retrograde cholangiopancreatography pancreatitis: a pilot study

2024-11-21T08:57:15+02:00

Background Following endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP pancreatitis (PEP) is the most common complication. The host’s innate immune response to periprocedural pancreatic injury is the hallmark of its pathogenesis. Investigating cytokine signatures associated with PEP and its risk factors can guide understanding of PEP immunopathogenesis.

Methods We conducted a single-center, prospective, observational pilot study in adults at high-risk for PEP. Seven serum cytokines relevant to early acute pancreatitis pathogenesis, angiopoietin-2, hepatocyte growth factor (HGF), interleukin-6 (IL-6), IL-8, monocyte chemotactic protein-1, resistin, and soluble tumor necrosis factor-α receptor 1, were measured in sera collected 2 h pre- and post-ERCP. Levels were compared among healthy controls and ERCP participants who either did or did not develop PEP. Heat maps were constructed to perform a multidimensional exploratory analysis that aimed to determine the cytokine signatures associated with PEP and its participant-related risk factors (female sex, young age, and obesity).

Results A total of 65 participants were enrolled (36 undergoing ERCP and 29 healthy controls). Eight of the 36 (22.2%) ERCP participants developed PEP. Baseline IL-8 levels measured before ERCP were elevated in participants who developed PEP (7.5 vs. 14.8 pg/mL, P=0.02), and most strongly upregulated in women under 40 years of age. HGF levels post-ERCP were higher in participants with PEP (738.0 vs. 556.6 pg/mL, P=0.04), and most strongly upregulated in obese participants.

Conclusions Pre-ERCP IL-8 and post-ERCP HGF are associated with the development of PEP. Findings from this pilot study can inform the design of translational work in the immunopathogenesis of PEP.

Keywords Acute pancreatitis, endoscopic retrograde cholangiopancreatography, post-ERCP pancreatitis, pathogenesis

Ann Gastroenterol 2024; 37 (6): 734-741

Paraduodenal pancreatitis as diagnostic challenge: clinical and morphological features of patients with pancreatic pathology involving the pancreatic groove

2024-11-21T08:57:15+02:00

Background Paraduodenal pancreatitis (PP) is an inflammation involving the groove zone, delimited by the duodenum lumen, bile duct, and the head of the pancreas. This area may also be involved during acute pancreatitis (AP). The differential diagnosis is clinically relevant, since PP generally persists, whereas AP resolves. Hence, we compared a cohort of patients with PP and AP involving the groove area.

Methods We retrospectively evaluated patients with pathology involving the groove area. The primary aim was to define the diagnostic features of PP compared to non-PP pancreatitis involving the groove area. PP was diagnosed by imaging, while AP was diagnosed according to the revised Atlanta classification and the clinical course, to exclude chronic pancreatitis.

Results The study population consisted of 37 patients (32 men, age 56.9±9.1 years), 25 with a diagnosis of PP (23 men, mean age 54.9±8.5 years), and 12 (9 men, mean age 61.2±9.2 years) with AP involving the groove. All 25 patients with PP and 4 (33.3%) with AP reported a history of alcohol abuse, 23 patients (92%) with PP, and 3 (25%) with AP had a history of smoking. On imaging, PP patients presented a significantly thicker duodenal wall compared to the AP group (P=0.010). Chronic pancreatitis in the body/tail and exocrine insufficiency was prevalent in PP (P<0.001 and P=0.02). The medial displacement of the gastroduodenal artery was more frequent in the PP group (P=0.011).

Conclusion PP has a different clinical and imaging profile compared to AP involving the groove area.

Keywords Paraduodenal pancreatitis, mass forming chronic pancreatitis, pancreatic necrosis, groove pancreatitis

Ann Gastroenterol 2024; 37 (6): 742-749

Impact of aspirin on pancreatic cancer in the elderly: analysis of socioeconomic status and outcomes of national matched cohorts

2024-11-21T08:57:15+02:00

Background Pancreatic cancer is a neoplastic condition with a high disease burden. It is projected to be the second most common cause of cancer-related deaths by 2030. However, evidence supporting the long-term use of aspirin in cancer prevention and treatment remains insufficient. We aimed to investigate the association between aspirin use and pancreatic cancer outcomes in the elderly population group.

Methods The 2020 National Inpatient Sample was used to investigate records of elderly patients admitted with pancreatic cancer, identified by ICD-10 CM codes. The data were categorized based on long-term aspirin use. We assessed inpatient mortality as the primary outcome, while secondary outcomes included costs and length of stay, as well as other inpatient complications.

Results We identified 19,249 hospitalizations of patients aged over 60 years. The mean age was 73.8 years, and 49.3% were male. In a survey multivariate logistic and linear regression model, adjusting for patient characteristics and hospital factors, long-term aspirin use was associated with lower inpatient mortality (adjusted odds ratio [aOR] 0.55, 95% confidence interval [CI] 0.33-0.92; P=0.023), a shorter hospital stay (beta coefficient -0.52, 95%CI -0.93 to -0.11; P=0.012), lower odds of acute kidney injury (aOR 0.76, 95%CI 0.59-0.98; P=0.039), and lower odds of shock (aOR 0.23, 95%CI 0.06-0.78; P=0.019]. Post-propensity matching revealed similar patterns.

Conclusions Long-term aspirin use is associated with a lower rate of inpatient mortality and other clinical outcomes in hospitalized elderly patients with pancreatic cancer. The etiologies behind this relationship should be explored with a view to better understanding.

Keywords Aspirin, pancreatic cancer, mortality

Ann Gastroenterol 2024; 37 (6): 750-757

Prognosis after curative resection of non-metastatic pancreatic neuroendocrine tumors: a retrospective tertiary center study

2024-11-21T08:57:15+02:00

Background Pancreatic neuroendocrine tumors (pNETs) are rare tumors with heterogeneous outcomes. The aim of our study was to determine the long-term outcome, recurrence patterns, as well as the clinical and pathological factors that impact time-to-recurrence (TTR), recurrence-free survival (RFS), and overall survival (OS) in pNETs treated with curative surgery.

Methods Data for all patients who underwent radical surgery with curative intent for nonmetastatic pNETs were obtained from a prospectively maintained database of the University Hospitals Leuven. Data from September 2002 until November 2021 were analyzed retrospectively. Patients with metastatic disease and/or neuro-endocrine carcinoma were excluded. Median follow-up time was calculated using the reverse Kaplan-Meier method. A Cox proportional hazards model was used to assess variables associated with recurrence.

Results The study included 128 patients. Only 8 patients (6.3%) had recurrent disease over a median follow up of 44.4 months (interquartile range [IQR] 29.8-74.7). The median TTR was 38.7 months (IQR 18.0-46.2). Univariate analysis showed that multiple endocrine neoplasia type 1 (MEN-1) and R1-status were statistically significant predictors for disease recurrence.

Conclusions In our series of patients treated with surgery for non-metastatic, well-differentiated pNETs, recurrence was low at 6.3%. MEN-1 and R1-status were predictors for recurrence in univariate analysis.

Keywords Neuroendocrine tumors, pancreatic neuroendocrine tumors, surgery, prognostic factors

Ann Gastroenterol 2024; 37 (6): 758-764