大阪医科大学

Background and study aims:Recently, antegrade procedures via the endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) have been developed as an alternative technique for failed endoscopic retrograde cholangiopancreatography However, time required for formation of endosonography-created route (ESCR) after EUS-HGS is still unknown. To prevent adverse events (AEs) after stent removal, stent removal using the through mesh technique might be useful. The aim of this study was to evaluate time to ESCR formation. Patients and methods:Consecutive patients who underwent EUS-HGS using self-expandable metal stents (SEMSs) and EUS-HGS stent removal for performing antegrade procedures were retrospectively enrolled. The primary endpoint was evaluation of the rate of ESCR formation. In the present study, EUS-HGS stent removal was attempted at approximately 14 days. Results:A total of 104 patients were enrolled in this study. EUS-HGS was performed using by partially covered SEMSs (n = 82) or fully covered SEMSs (n = 22). EUS-HGS stent removal was successfully performed in 102 patients (98.1%). Median interval prior to EUS-HGS stent removal in the study subjects was 13 days (range 12-14 days). Among patients who underwent EUS-HGS stent removal, ESCR formation was confirmed in all cases. Mean procedure time was 24.0 minutes. The rate of AEs was 2.9% (3/104)and all AEs were successfully treated conservatively. Conclusions:In conclusion, ESCR may have been established by a median of 13 days following EUS-HGS using SEMS; however, time to ESCR formation should be evaluated in a future study.

BACKGROUND & AIMS:Direct-acting antiviral agents (DAA)-mediated HCV cure correlates with better outcomes, but there are insufficient data on detailed mortality-related risk factors after cure. This study sought to clarify mortality and associated risk factors post-HCV cure. METHODS:The study included HCV patients with sustained virological response following DAA (DAA-SVR) from 39 REAL-C centres in North America, Europe and Asia-Pacific. The primary outcome was all-cause mortality in DAA-SVR patients. Mortality rate per 1000 patient-years (PY) was calculated as the number of deaths divided by total PY multiplied by 1000. RESULTS:A total of 10 034 DAA-SVR patients (stratified by cirrhosis status: 5611 non-cirrhosis, 4153 compensated, 270 decompensated) were included. With a median follow-up of 4.76 PY, 4.9% (491) died. The all-cause mortality rates were 6.2, 13.1, 60.0 and 10.4 per 1000 PY for patients without cirrhosis, compensated and decompensated cirrhosis, and overall patients, respectively. The 5-year cumulative survival was 95.1% (94.5%-95.6%) overall, with the lowest rate of 73.9% (67.0%-79.5%) in decompensated cirrhosis. Non-liver-related death was the main cause in non-cirrhosis (non-liver-related vs. liver: 5.2 vs. 0.8 per 1000 PY)/compensated cirrhosis (8.2 vs. 4.8 per 1000 PY), while liver-related death was dominant in decompensated cirrhosis (24.7 vs. 33.8 per 1000 PY). Risk factors for higher mortality included age > 65 (3.2-fold), male (1.5-fold), cirrhosis (decompensated 7.6-fold) and baseline DM (1.5-fold). CONCLUSION:This study showed significant age, sex, fibrosis stage and DM differences in mortality and causes among DAA-SVR patients. It provided granular subgroup data for precision medicine to support individualised care, future modelling studies and public health planning.

BackgroundZinc deficiency has been identified as an important factor contributing to chronic nutritional disorders in maintenance hemodialysis (HD) patients.AimWe assessed the long-term effect of zinc replacement therapy on all-cause mortality among patients undergoing HD.MethodsThis posthoc analysis utilized data from an open-label, multicenter, randomized, active-controlled study including HD patients aged 40-94 years, registered between December 2019 and May 2020. Patients who initiated zinc supplementation were categorized into two groups based on treatment status 12 months after initiation: continuation (n = 46) and discontinuation (n = 22). The primary outcome was 4-year all-cause mortality. Survival was compared by Kaplan-Meier analysis, and hazard ratios (HRs) were estimated using Cox proportional hazards models.SummaryThe 4-year survival rate was higher in the continuation group (54.8%) than in the discontinuation group (33.9%, log-rank P = 0.122). Continuation of zinc therapy significantly reduced mortality risk (HR: 0.33, 95% CI: 0.11-0.95, P = 0.041). Independent predictors of mortality included age (HR: 1.09 per year), female sex (HR: 2.46), primary kidney disease (HR: 2.81), serum albumin <3.5 g/dL (HR: 4.35), transthyretin <20 mg/dL (HR: 3.59), and phosphorus <3.7 mg/dL (HR: 3.28). Subgroup analysis revealed that albumin ≥3.5 g/dL was protective in the continuation group, while malnutrition and inflammation markers were strongly associated with mortality in the discontinuation group. Continuation of zinc replacement therapy was associated with significantly improved survival in HD patients. These findings suggest that sustained supplementation may provide prognostic benefit, particularly in those with preserved nutritional status.RegistrationThe study was registered with the University Hospital Medical Information Network (UMIN) under registration number 000038759.

INTRODUCTION:Direct-acting antiviral agents effectively cure chronic hepatitis C (CHC), whereas curative therapy for chronic hepatitis B (CHB) is rare. We aimed to compare hepatocellular carcinoma (HCC) incidence between suppressed CHB vs cured CHC patients with cirrhosis. METHODS:We analyzed 5,773 cirrhosis patients from 43 centers in 9 countries: 1,877 with treated and suppressed CHB and 3,896 with direct-acting antiviral agents-cured CHC using inverse probability treatment weight and competing risk analysis through Fine and Gray method. RESULTS:After inverse probability treatment weight (on age, sex, ethnicity, study location, albumin, total bilirubin, creatinine, platelet, tobacco use, alcohol use, diabetes mellitus, hypertension, hyperlipidemia, cardiovascular disease, steatotic liver disease, obesity, and follow-up years), 2 study groups became similar in relevant characteristics. The 5-year cumulative HCC incidence was significantly higher in suppressed CHB compared with cured CHC (18.1% vs 7.4%, P < 0.001) with consistent findings in subgroups by sex and Model for End-Stage Liver Disease (all P < 0.021), fast CHB responders (time from treatment to viral suppression <1 year) ( P < 0.001), and CHB suppressed for <2 years ( P < 0.001), but not among CHB suppressed for ≥2 years whose HCC incidence was similar to those of cured CHC ( P = 0.954). On multivariable analysis, CHB suppression <2 years as compared with cured CHC (subdistribution hazard ratio 20.92, P < 0.001) and total bilirubin (subdistribution hazard ratio 0.71, P = 0.04) were associated with higher HCC risk. DISCUSSION:HCC risk remains high in both treated and suppressed CHB cirrhosis and cured CHC cirrhosis. However, with prolonged CHB suppression, risk of HCC can be reduced, highlighting benefits of early treatment and viral suppression in patients with CHB.

Background and study aims Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an effective and safe therapeutic option for biliary drainage in patients with malignant biliary obstruction (MBO). Several authors proposed use of antegrade stenting (AS) combined with EUS-HGS to improve long-term outcomes, with controversial results. We aimed to assess pooled performance of EUS-HGS+AS compared with EUS-HGS alone. Methods Database search was performed to identify studies comparing EUS-HGS+AS to EUS-HGS alone for biliary drainage in patients with MBO. Primary outcome was recurrent biliary obstruction (RBO). Secondary outcomes were technical, clinical success, adverse events (AEs), severe AEs rate, time to RBO, and overall survival (OS). Relative risks (RRs) with 95% confidence intervals (CIs) were calculated using random-effect model. Results Five studies involving 555 patients were retrieved. RBO was lower in patients who underwent EUS-HGS+AS (RR 0.30; [0.18-0.49]; P < 0.001). Pooled technical success, clinical success, AE, and severe AE rates were similar (RR 0.94 [0.85-1.05], RR 1.02 [0.94-1.11], RR 0.88 [0.50-1.55]), and 0.26 [0.03-2.22], respectively). Time to RBO was higher in EUS-HGS+AS (SMD + 4.02 [0.57-7.47]; P = 0.04). Mean procedure time was similar among the groups (SMD +0.38 [-0.12-0.87]; P = 0.13) as well as OS was similar in the two groups (SMD 0.18 [-0.20-0.52]; P = 0.85). Conclusions Combining AS with EUS-HGS reduces RBO risk in patients with MBO, without impact on technical, clinical success rates, or safety profile. Randomized controlled trials are needed to confirm these observations.