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Prediction of Pancreatic Cancer Risk in Patients with New-Onset Diabetes

Background: Pancreatic cancer remains the fourth leading cause of cancer-related deaths in the USA despite its lower incidence, primarily due to late-stage diagnosis. While early detection could double survival rates, screening the general population is not cost-effective due to low disease prevalence and technical limitations. Summary: This review examines the relationship between diabetes and pancreatic cancer, highlighting how diabetes types differently impact cancer risk. New-onset diabetes triples pancreatic cancer risk compared to the general population, while long-standing diabetes doubles it. Several prediction models have been developed to identify high-risk individuals among new-onset diabetes patients, with recent models achieving AUCs up to 0.91. Current biomarkers like CA 19-9 show improved utility when combined with other clinical parameters, though they remain inadequate for general population screening. Cost-effectiveness analysis suggests that screening becomes viable when 3-year cancer incidence exceeds 2% and 25% of cases are detected at a localized stage. Key Messages: (1) New-onset diabetes presents a stronger risk factor for pancreatic cancer than long-standing diabetes. (2) Multiple prediction models show promise but face challenges with missing data and cross-population validation. (3) Integrated approaches combining clinical parameters, biomarkers, and machine learning offer the most promising path forward for early detection. (4) Current detection rates fall below cost-effectiveness thresholds, highlighting the need for improved screening strategies.

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Open Access
Efficacy of a Shortened Oral Antibiotic Bowel Decontamination in Minimally Invasive Surgery for Diverticular Disease

Introduction: Infectious complications, such as anastomotic leakage (AL) and surgical site infections (SSIs), remain a significant challenge in colorectal surgery. Consequently, there is growing interest in oral antibiotic bowel decontamination with nonabsorbable antibiotics (selective digestive decontamination or SDD), which can reduce perioperative complications while also minimizing antibiotic use. This study aimed to determine whether a 3-day SDD regimen is as effective as a 7-day regimen in preventing postoperative complications in laparoscopic diverticular surgery. Methods: A bicenter data analysis of prospectively and retrospectively collected patient data was performed. A 3-day versus 7-day perioperative use of an SDD-based regimen (polymyxin B, gentamicin, vancomycin, and amphotericin B) in patients undergoing minimally invasive surgery for diverticular disease was compared using noninferiority analysis. Results: A total of 469 patients were included in the analysis: 101 patients received a 3-day perioperative SDD regimen, while 368 patients received a 7-day regimen. Due to the use of routine clinical data, no control cohort is available. The overall complication rate was 16.5% in both groups. AL and SSI occurred in 2.0% and 6.0% of the 3-day group, and in 1.4% and 6.3% of the 7-day group, respectively, with no significant differences between the groups. However, for wound infections and overall infectious complications, the 3-day regimen can be considered noninferior to the 7-day regimen. Our data did not confirm the noninferiority of the SDD3 regimen compared to the SDD7 regimen for AL. Discussion: We report low rates of AL and other surgical and nonsurgical complications in minimally invasive diverticular disease surgery. The low complication rates demonstrate noninferiority regarding SSI. Our findings are consistent with recent evidence, highlighting the positive impact of perioperative SDD treatment on SSI and infectious complications.

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Use of Histomorphological Features for the Prediction of Grade C Fistula after Whipple Procedure: A Difficult Task

Introduction: The prediction of occurrence and form of a postoperative pancreatic fistula (POPF) could decrease the risk after pancreatic resections. We developed a score based on histomorphological criteria to predict POPF earlier on. In this study, we test the scoring system to differentiate between patients developing grades B and C POPF. Methods: We analysed 92 patients who underwent pancreatic head resection and developed a grade B or C POPF postoperatively. There were no exclusion criteria. Pancreatic resection margins were analysed histologically and pancreatic duct size, fibrosis, fat content, and signs of inflammation were transformed into a scoring system. Results: Patients with a grade B fistula (n = 48) were compared to patients with grade C fistula (n = 44). The grade C group was characterized by higher mortality (0 vs. 22, p < 0.001), postpancreatectomy haemorrhage (3 vs. 24, p < 0.001), longer stays in intensive care unit (2.6 vs. 21.1, p < 0.001) and in hospital (29.8 vs. 44.6, p < 0.001). The scoring system was unable to predict grade C fistula. We calculated receiver operator characteristics for all assessed characteristics, which revealed an area under the curve of 0.561. The strongest predictors of POPF grade C were pancreatic fat and soft pancreatic tissue. A combination of only these two items led to a statistically significant difference (p < 0.001) and an AUC of 0.771. Conclusion: Establishing a score to differentiate between grade B and grade C POPF is a difficult task. Pancreatic fat seems to be the most relevant histomorphological feature to be used in any scoring system, and it should be combined with other clinical features to enhance its precision and validity.

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Oncologic Surgery for Lower Gastrointestinal Tumors during Pregnancy: A Literature Review

Background: Colorectal cancer (CRC) during pregnancy can be a challenging situation due to the spatial confinement of the tumor with the growing uterus carrying the fetus. It is one of the more common tumor entities occurring in pregnant women, and therefore, it has to be taken into account if “patients describe suspicious” symptoms. Summary: Diagnosis and treatment are complex and require a specialized multidisciplinary team of visceral oncologists with expertise in colorectal surgery, gastrointestinal oncologists, gynecologists, obstetricians, and neonatologists to coordinate the optimal treatment plan with the patient. Multimodal treatment options depend on gestational age and tumor stage. Radical surgical oncologic therapy at the latest possible stage of pregnancy is often the only feasible, potentially curative treatment option. Chemotherapy and radiotherapy should be postponed to the postpartum period, if possible. Neonatological aspects, including the high risk of serious complications for the infant during and after anesthesia for oncologic surgery, such as cerebral hemorrhage, pulmonary hypoplasia, and necrotizing enterocolitis, must always be in the focus when considering the optimal timing of surgery, as well as the prognosis of the mother concerning her tumor. Key Message: Treatment of CRC during pregnancy is based on highly individualized therapeutic decisions rather than on standardized guideline recommendations. Surgical resection via partial colectomy, anterior rectal resections, and abdominoperineal extirpations are feasible. However, it has always to be considered if surgery has to be performed in elective situations or damage control procedures due to emergencies, such as mechanical ileus or perforations with intra-abdominal sepsis.

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Open Access
Appendicitis in Pregnancy: A Multidisciplinary Approach and Optimal Management from the Perspective of Gynecology and Obstetrics – A Case Report

Introduction: Appendectomy for acute appendicitis is the most common surgical procedure performed during pregnancy. The primary treatment for acute appendicitis is emergency surgery, which can be particularly challenging due to altered anatomical conditions. Preoperative and postoperative care may require certain examinations due to pregnancy that are not standard within surgical practice or may be overlooked by the attending gynecologist. Case Presentation: A patient at 31 weeks of gestation presented to the obstetric clinic with an acute onset of acute appendicitis. After completing all necessary examinations and a thorough multidisciplinary evaluation, a successful laparoscopic appendectomy was performed. The subsequent hospitalization was complicated by the onset of uterine contractions, for which tocolysis was administered in combination with corticosteroid therapy to induce fetal lung maturity. Conclusion: In the presented case report, we demonstrate an example of the appropriate multidisciplinary approach with an analysis of the specific steps that should be taken to maximize the benefit for both the fetus and the mother, as well as the surgical team. In the discussion, we outline the steps that should be followed for patient benefit and forensic reasons.

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Open Access
Discrimination between Inflammatory and Fibrotic Activity in Crohn’s Disease-Associated Ileal-Colonic Anastomotic Strictures by Combined Ga-68-FAPI-46 and F-18-FDG-PET/CT Imaging

Introduction: The development of an intestinal stricture in patients with Crohn’s disease represents an important and frequent complication, reflecting the progressive nature of the disease. Depending on the inflammatory and fibrotic composition of the stricture, intensified medical therapy, interventional endoscopy, or surgical intervention is required. However, currently available diagnostic approaches can only assess the level of inflammation, but not the degree of fibrosis, limiting rational therapeutic management of Crohn’s disease patients. Recently, prolyl endopeptidase fibroblast activating protein (FAP) has been functionally implicated in fibrotic tissue remodelling, indicating it as a promising target for detection of sites of fibrotic tissue remodelling. Thus, intestinal fibrosis might be visualized using Gallium-68 labelled inhibitors of FAP (FAPI). While F-18-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT is a standard diagnostic tool for visualizing inflammatory processes, we combined Ga-68-FAPI-46-PET/CT and F-18-FDG-PET/CT to differentiate predominantly fibrotic or inflammatory areas in Crohn’s disease patients with ileo-colonic strictures. Methods: In our study, we analysed three Crohn’s disease patients with anastomotic ileo-colonic strictures who underwent both dynamic Ga-68-FAPI-46-PET/CT and static F-18-FDG-PET/CT imaging to assess the level of visualized fibrotic areas within the stricture and differentiate it from inflammatory ones. PET images were analysed both visually and quantitatively. Furthermore, conventional MR enterography and endoscopy were performed in parallel to correlate observed findings. Two of the included patients underwent surgery and the histological specimen were analysed for the level of inflammation and fibrosis, which results were similarly compared to the findings of the PET imaging procedures. Results: Different uptake patterns of Ga-68-FAPI-46 could be observed in the anastomotic ileo-colonic strictures of the examined Crohn’s disease patients, respectively. Immunohistochemical analyses demonstrated that there was a correlation between the level of Ga-68-FAPI-46 uptake and severity of fibrosis, while FDG uptake correlated with the inflammatory activity in the analysed strictures. Discussion: The combination with F-18-FDG-PET/CT represents a promising imaging modality to distinguish inflammation from fibrosis and guide subsequent therapy in stricturing Crohn’s disease patients, warranting further studies.

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Open Access
Current Treatment Options in Neuroendocrine Tumors of the Appendix

Background: While appendiceal neuroendocrine tumors (aNETs) are rare, they are the most common type of appendiceal neoplasms, often discovered incidentally during surgeries for acute appendicitis. Appendiceal NETs are typically well-differentiated and associated with an excellent prognosis after adequate surgical therapy. Summary: Management of aNETs depends on tumor size, grade, and risk factors for lymph node and metastasis. Current guidelines from the European Neuroendocrine Tumor Society (ENETS) recommend appendectomy only for low-risk tumors (<1 cm) and more extensive resection (right hemicolectomy [RHC]) for high-risk tumors (>2 cm or incomplete resection). However, the management of intermediate-sized tumors (1–2 cm) remains debated as RHC may not improve survival. Risk factors such as lymphovascular invasion or mesoappendiceal infiltration over 3 mm may prompt RHC consideration. However, current evidence suggests that long-term outcome is not affected by the extent of surgery in aNETs 1–2 cm in size questioning the necessity of RHC in these cases. Advanced metastatic aNETs, extremely rare in occurrence, follow treatment guidelines similar to other gastroenteropancreatic NETs and may involve multimodal therapy, including surgery, radiological interventions, and systemic treatment tailored to the patient’s condition and disease burden. Key Messages: Appendectomy is adequate for most aNETs, particularly those smaller than 1 cm, G1, and without high-risk features. RHC is recommended for tumors larger than 2 cm, but for tumors 1–2 cm, evidence increasingly suggests that RHC may not confer a survival benefit. Metastatic aNETs are rare, and individualized, multidisciplinary therapy approaches are recommended.

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