Editorial
Dear colleagues,
The strategy of intermittent fasting, or eating only at certain times of day, is frequently recommended to individuals striving to lose weight. A randomized study in obese patients investigating this time-restricted eating approach showed that eating between 8:00 a.m. and 4:00 p.m. with calorie restriction was not superior to calorie restriction alone with no time restriction with regard to weight loss. There were also no differences in adverse effects of the diets or metabolic risk factors (Liu et al.). Obesity is also a major risk factor for gastroesophageal reflux disease (GERD). In addition to medical and surgical interventions, endoscopic approaches are also under evaluation for the treatment of GERD. For example, a new pilot study now reports major short- and long-term improvement in quality of life and reflux symptoms in GERD patients using endoscopic full-thickness fundoplication versus a sham procedure (Kalapala et al.). [...]
A number of treatment algorithms have been investigated for inflammatory bowel disease (IBD) in recent years. For example, the CALM study demonstrated that monitoring of objective disease activity in Crohn’s disease patients at defined intervals using the biomarkers calprotectin and C-reactive protein to guide the decision to escalate treatment could improve response rates to adalimumab therapy. However, in a similar study using ustekinumab (STARDUST), early dose escalation guided by endoscopic, clinical and laboratory end points (treat-to-target, T2T) did not result in significant improvement in endoscopic end points after 48 weeks versus standard of care. Further analyses are required to determine whether the T2T approach with ustekinumab might nonetheless be beneficial for certain defined patient subgroups (Danese et al.). Endoscopic colorectal cancer screening has seen a growth in the use of machine learning and artificial intelligence technologies designed to improve the adenoma detection rate (ADR). This raises the question of whether such assistive technologies might provide a similar benefit to relatively “novice” endoscopists as it does for their more experienced colleagues. In a recent study from Italy, computer-aided polyp detection also significantly improved ADR among less experienced endoscopists. Furthermore, a separate analysis comparing the results from this study to a study with experienced endoscopists suggests that experience with endoscopy might only play a minor role in ADR outcomes (Repici et al.). The marked rise in the incidence of colorectal cancer (CRC) also includes younger patients in many countries, creating an urgent need to identify risk factors for the disease. A German population-based case-control study now reports that obesity as a young adult is a significant risk factor for an early onset of CRC (Li et al.).
While cholecystectomy is recommended following acute necrotizing biliary pancreatitis, the optimal time point for this intervention remains unclear. A Dutch study on a prospective patient cohort with necrotizing biliary pancreatitis has now reported that the ideal time point for cholecystectomy is within 8 weeks after discharge provided patients have no peripancreatic fluid collection due to their necrotizing pancreatitis (Hallensleben et al.). Preventing postoperative complications following pancreatic resection is a major goal in routine clinical practice. A nationwide study in the Netherlands has found that use of a standardized postoperative care algorithm for the early recognition and management of postoperative complications can reduce postoperative mortality by nearly half and can significantly lower the rates of complications such as organ failure and bleeding (Smits et al.). Based on these results, such structured approaches should be developed further and implemented.
New pharmaceuticals specifically developed to achieve a “functional cure” of chronic hepatitis B (with functional cure defined as hepatitis B surface antigen [HBsAg] loss) have yet to materialize. Nonetheless, there is hope of achieving functional cure using existing drugs according to the strategy of stopping NA therapy. According to current guidelines, long-term nucleos(t)ide analogue (NA) therapy can be discontinued in hepatitis B e antigen (HBeAg)-negative patients without advanced fibrosis/cirrhosis as long as they are monitored closely. A considerable percentage of these patients then achieve HBsAg clearance, likely through immune-mediated mechanisms. Two recent large cohort studies with more than 1000 subjects each have shown that low HBsAg levels (< 1000 IU/ml, or even better < 100 IU/ml in Asian patients in particular) as well as (when available) negative hepatitis B core-related antigen (HBcrAg) before discontinuation of NUC therapy are good predictors of a functional cure (Hirode et al.; Sonneveld et al.). Despite representing the standard of care for hepatocellular carcinoma (HCC) for more than a decade, sorafenib was de facto replaced as the first-line therapy for HCC by atezolizumab plus bevacizumab following evidence of the superiority of this combination several years ago. Encouragingly, in the IMbrave150 pivotal trial, overall survival among patients receiving atezolizumab plus bevacizumab was so long that median overall survival was not reached. A subsequent publication has updated these results following an extended follow-up in the study patients: Median overall survival across the follow-up period was 19.2 months (95% confidence interval [CI]: 17.0–23.7) with atezolizumab plus bevacizumab versus 13.4 months (95% CI: 11.4–16.9) with sorafenib (Cheng et al.). These results clearly underscore the finding that this relatively new immunotherapy can greatly improve the prognosis of HCC.
We hope you find the literature selection in this issue of the Falk Gastro Review Journal exciting and engaging, and wish you a sunny autumn!
Happy reading,
Christoph Neumann-Haefelin and Peter Hasselblatt
Department of Internal Medicine II, Medical University Clinic of Freiburg (Germany)
Christoph Neumann-Haefelin
Peter Hasselblatt