Introduction

Informed consent (IC) serves as the ethical foundation for all medical interventions, empowering patients to make informed, autonomous decisions while safeguarding clinicians. Barriers such as limited health literacy and document complexity may hinder comprehension^1,2. This study evaluated the comprehensibility, readability, and effectiveness of the documents provided for IC and instructions for endoscopic procedures.

Aims & Methods

Outpatients undergoing endoscopic procedures completed a questionnaire assessing their understanding of IC, preparation instructions, and adherence to guidelines. Patient confidence and document comprehensibility were assessed through self-reported scales. Readability was assessed using Flesch Reading Ease score adapted for portuguese (FRE-PT)³.

Results

Among 186 participants (mean age: 58.1 ± 16.1 years), 76.9% reported full-extent reading of the provided instructions and IC document. Patients with primary education (≤4th grade) were less likely to read the documents fully (59.2% vs. 83.2%, p < 0.001) and were independently associated with the need for additional assistance (OR 5.65, 95% CI: 1.92 - 16.68, p = 0.002). Full-extent reading was independently associated with greater risk awareness (OR 5.52, 95% CI: 2.37 - 11.55, p < 0.001), reduced need for additional assistance (OR 0.22, 95% CI: 0.09 - 0.51, p < 0.001), and higher compliance with medication guidelines (75.7% vs. 45.8%, OR 3.42, 95% CI: 1.28 - 9.20, p = 0.015). Patients with primary education rated document’s comprehensibility lower (median:8, IQR 7-10) compared to those with higher education (median: 10, IQR 8 - 10, p < 0.001) and reported lower levels of confidence and preparation for the procedure (median: 8, IQR 7 - 10 vs. median: 9, IQR 8 - 10; p = 0.018). Outcomes did not differ significantly between patients aged 65 years or older compared to younger patients. FRE-PT scores classified readability as ‘’very difficult’’ for both upper endoscopy (20.87) and colonoscopy (26.00).

Conclusion

Full-extent reading IC and instruction documents reduces the need for assistance, improves compliance with pre-procedural measures, risk awareness and patient confidence. However, the document’s complexity and difficult readability disproportionately challenge and discourage patients with limited education. Future research should explore strategies to foster more equitable informed decision-making.

References

1. Protheroe J, Rowlands G. Matching clinical information with levels of patient health literacy. Nurs Manag (Harrow). 2013;20(3):20-21. doi:10.7748/nm2013.06.20.3.20.e1095
2. Ley R, Forio T. The use of readability formulas in health care. Psychol Health Med. 1996;1(1):7-28.
3. Martins TBF, Ghiraldelo CM, Nunes MGV, Oliveira Junior ON. Readability formulas applied to textbooks in Brazilian Portuguese. 1996.

Introduction

Acute biliary pancreatitis (ABP) has been shown to be associated with increasing incidence and health-care costs, and possibly higher mortality than other etiologies. Despite the existence of various scoring systems, early and accurate risk stratification remains difficult. Due to heterogeneity of populations, focusing on one etiology might reveal important insights concerning predictors of outcome.

Aims & Methods

We conducted a retrospective, multicenter cohort study including all patients admitted with ABP between 2018 and 2021 at two hospitals. Epidemiological, clinical, and outcome data were analyzed. The main clinical outcome of interest was a hierarchical composite endpoint of five mutually exclusive clinical states: (i) death (90-day all-cause mortality), (ii) severe AP and/or admission to the intensive care unit (ICU), (iii) endoscopic, interventional radiological, or surgical interventions, (iv) moderately-severe AP, (v) mild AP. Univariable logistic regression identified parameters associated with worse outcomes, which were then tested in multivariable models. Emphasis was placed on early availability and clinical practicality of predictors. We aimed to stratify patients into outcome trajectories reflecting both health impact and healthcare resource utilization.

Results

Out of 569 total acute pancreatitis cases, 217 (38.1%) patients had ABP (mean age 65.9 ±17.4 years; median length of stay (LOS) 7 days, IQR 4;11) Mild, moderately-severe, and severe disease occurred in 62.2%, 30.0%, and 7.8% of patients. All-cause 90-day mortality was 2.3%. Several parameters were significantly (p<0.05) associated with worse outcomes, including BISAP and the Charlson comorbidity index (CCI) (p<0.001). Individually, BISAP and CCI classified patients reasonably, however, wide prognostic uncertainty persisted. When combining BISAP and CCI (BISAP-C), 5 discrete risk groups were identified, ranging from low (group 1, BISAP 0-2 & CCI 0-2) to very-high risk (group 5, BISAP 3-5 & CCI ≥6) (see Table 1). The prevalence of severe outcomes (i–iii) increased across these strata: 2.4% (Group 1), 9.5% (Group 2), 27.3% (Group 3), 60% (Group 4), and 62.5% (Group 5), with LOS also significantly longer in higher-risk groups (p<0.001). Mortality was 50% in group 5, while, importantly, 97.6% of patients in group 1 experienced mild-to-moderate AP without ICU admission, persistent organ dysfunction, surgical or endoscopic interventions, and no fatality, supporting potential early discharge. This also occurred in 90.5% of group 2. Notably, Groups 1 and 2 together comprised nearly 80% of the cohort.

Conclusion

Comorbidity seems to play a major role concerning worse outcomes in ABP. The combination of CCI and BISAP (BISAP-C), both comprised of early-on and easily available parameters, offers improved early prognostic discrimination and may provide tailored, individualized management and healthcare resource utilization.

Clinical Case Summary

A 66-year-old female patient with a history of duodenal peptic ulcer disease was referred for evaluation of an 8 mm sessile polyp (Paris 0-ls) located in the terminal ileum. The polyp was excised during a colonoscopy with ileoscopy performed at a private facility in the context of colorectal cancer screening. Histological analysis revealed a well-differentiated NET (Grade 1) in the mucosal and submucosal layers of the terminal ileum, measuring 5.6 mm, with an endoscopic resection achieving R0 status (IVL0, 170 µm from the vertical margin). Following multidisciplinary discussion, staging was performed using CT of the abdomen and pelvis, enterography CT, and 68-Ga PET, which showed an ileocolic lymphadenopathy with high expression of somatostatin receptors and elevated serum Chromogranin A (238.7; N<85). A decision was made to reevaluate with 68-Ga PET in four months to determine the course of action regarding surgery versus chemotherapy. Due to the persistence of findings and after further multidisciplinary discussion, a right hemicolectomy with laparoscopic lymphadenectomy was performed. The procedure revealed no mural lesions; however, 5 out of 20 ileocolic lymph nodes were positive for TNE invasion (ypT1N1M0, Ki-67 <1%, mitotic index <1/10 HPF, stage III). The follow-up at five months showed no recurrence.
This case highlights the importance of ileoscopy during colonoscopy, even in the absence of symptoms, in order to exclude lesions of the small intestine. Given their aggressive nature, increasing incidence, and more frequent ileal location, the performance of ileoscopy during total colonoscopy offers significant clinical benefit without a substantial increase in procedure time, even in asymptomatic individuals.This case also highlights the challenge of histopathological criteria in defining curative disease after endoscopic resection and the discrepancy between pre- and post-operative imaging and functional staging, with prognostic and surveillance implications.

References

Joana Carvão, Mário Dinis-Ribeiro, Pedro Pimentel-Nunes, Diogo Libânio; Neuroendocrine Tumors of the Gastrointestinal Tract: A Focused Review and Practical Approach for Gastroenterologists. GE Port J Gastroenterol 1 September 2021; 28 (5): 336–348.

Introduction

There is minimal data to support a recommendation to perform colonic stenting (SEMs) in the right colon, but particularly in malignancy in the region of the ileocaecal valve, where only small bowel dilatation results from obstruction. This scenario poses technical challenges in endoscopic access in unprepared proximal colon, and relating to the anatomy of the ileocaecal valve. One recent case series included 13 patients with reported success rate and equivalent outcomes to left-sided stents with median survival of 4 months, although a two-step procedure was described¹.

Aims & Methods

In our centre we attempt self-expanding metal stent insertion (SEMs) in cases of malignant ileocaecal obstruction, which constitutes ~9% of our overall SEMs caseload. We report our outcomes and, as an important metric for palliative patients, stoma-free survival in the context of colorectal cancer management. We perform stenting using colonoscopy to access the stricture and fluoroscopy for wire and stent deployment, with both over the wire and through the scope techniques.

Results

25 patients, median age 77 years, underwent intention to stent for colorectal malignancy at the ileocaecal junction, where stent deployment into the ileum would be necessary to overcome the obstruction. Clinical success with life-time avoidance of surgery or stoma was 68% without any adverse events from attempting SEMs. Median survival was 206 days, compared to 167 days in those where stenting was unsuccessful. This was not significantly different to median stoma-free survival of 272 days for all SEMs patients in our database. One patient, after technically successful stent deployment, re-obstructed within 7 days and underwent surgery. There were no other early or late complications in either group. Reasons for technical failure in 6 cases was inability to pass a wire into the ileum, bowel preparation in 1 case, and failure to adequately resolve obstruction in the aforementioned patient.

Conclusion

Stenting malignant colonic obstruction of the ileocaecal region is more technically challenging but does not appear to disadvantage patients after an unsuccessful procedure. Stoma or surgery is avoided in 68% cases in intention to treat analysis of 25 patients and median survival of 206 days is equivalent to other colonic stent locations.

References

1. Fujisawa et al. J. Clin. Med. 2025, 14(3), 826