Clinical Case Summary

A 33-year-old female patient was referred to the emergency after a polytrauma. CT scan showed a fracture of the pelvis as well as rupture of the anteroinferior wall of the urinary bladder. Conservative treatment of the bladder injury with indwelling urinary catheter was indicated and an orthopedic surgery was performed. During the immediate postoperative period, the patient had urine leaking through the suprapubic surgical wound. A second surgery was indicated by the Urology team, who sutured bladder injury. After 3 days, high volume of urine leaked through the surgical wound (2,5 L per day). A bilateral ureteral catheter was inserted to divert urinary flow but without improvement. The endoscopy team was asked to assess the possibility of vacuum therapy. Flexible cystoscopy jointly conducted by the urology and endoscopy teams identified a fistula in the right anterior wall of the bladder that communicated with surgical wound dehiscence. A Teflon guide wire was passed through the fistula and exteriorized through the skin orifice. A size 12 urethral tube was passed through the guide wire and the urethra, with the distal end externalized through the skin wound. The tube was adapted with fenestrated film (modified vacuum therapy) and a thread (2-0 Ethibond) was left at the distal end to serve as a guide for future changes. Under direct vision, the catheter was pulled and placed in the fistulous tract. An occlusive dressing was applied to the surgical wound and a functioning vacuum was achieved. The indwelling urinary catheter and antibiotic therapy were continued during treatment. A reduction in urine output through the surgical wound was observed. The catheter was changed once a week guided by cystoscopy using the thread left during the first procedure. Two changes were made, with a total treatment duration of 21 days. The urine output from the surgical wound had ceased completely. The control tomography showed complete closure, with no contrast extravasation.

Introduction

Colonic polypectomy is a widely used endoscopic technique for colorectal cancer prevention. However, post-polypectomy bleeding (PPB) and local recurrence remain notable complications. Snare Tip Coagulation (STC) involves the application of thermal coagulation to the resection margin using the tip of the snare after polyp removal. This study aimed to evaluate the clinical efficacy of STC in reducing immediate and delayed PPB, as well as local recurrence, following polypectomy.

Aims & Methods

We retrospectively reviewed 156 patients who underwent endoscopic resection—either snare polypectomy or endoscopic mucosal resection (EMR)—for pedunculated or sessile colorectal polyps measuring 6–20 mm at a single center between January 2022 and February 2024. Patients were divided into two groups: those who received STC (n=78) and those who did not (control group, n=78). Primary outcomes included the incidence of PPB within 14 days and local recurrence at 12-month follow-up colonoscopy.

Results

The STC group demonstrated significantly lower rates of early (0.4%) and delayed (1.6%) PPB compared to the control group (1.9% and 3.8%, respectively; p<0.05). Local recurrence was also significantly reduced in the STC group (1.3%) versus the control group (4.8%; p=0.01). No significant differences were observed between the groups regarding procedure time or major complications such as perforation.

Conclusion

Snare Tip Coagulation is a safe and effective adjunctive technique in colorectal polypectomy, significantly reducing the risk of both post-procedural bleeding and local recurrence without increasing procedural complications. STC may offer particular benefit in the resection of medium-sized colorectal adenomas and should be considered for integration into routine endoscopic practice.

References

1. ​Snare Tip Soft Coagulation vs Argon Plasma Coagulation vs No Margin Treatment After Large Nonpedunculated Colorectal Polyp Resection: a Randomized Trial. Douglas K Rex, Gregory B Haber, Mouen Khashab, et al. Clin Gastroenterol Hepatol. 2024 Mar;22(3):552-561.e4.
2. Recurrences of advanced sessile and lateral spreading colorectal adenoma after endoscopic mucosal resection (EMR) thermal ablation versus no adjuvant therapy (RESPECT): a protocol of an international randomized controlled trial. Kemper G, Gerges C, Schoon EJ, Schreuder RM, Schrauwen RRW, Epping LSM, Beyna T, Drenth JPH, Gündug U, Siersema PD, van Geenen EJM; ENDOCARE study group.Trials. 2024 Feb 17;25(1):132. doi: 10.1186/s13063-024-07915-2.

Disclosure

Nothing to disclose

Introduction

Hepatocellular carcinoma (HCC), the sixth most prevalent malignancy and third leading cause of cancer-related mortality globally, accounts for 75-85% of primary liver cancers with a 5-year survival rate below 20%. Early-stage HCC is managed by resection or ablation, while advanced cases rely on transarterial therapies and systemic treatments. However, drug resistance to multi-kinase inhibitors (e.g., sorafenib) significantly limits efficacy. HCC progression is closely linked to an immunosuppressive tumor microenvironment characterized by T-cell co-stimulatory molecule deficiency and checkpoint activation (PD-L1/CTLA-4), driving T-cell exhaustion. Recent evidence highlights intratumoral microbiota dysbiosis as a modulator of immune remodeling, yet the spatial distribution patterns and regulatory mechanisms of bacterial communities within HCC lesions remain poorly defined.

Aims & Methods

This study employed invasion-adhesion-directed expression sequencing (INVADE-seq) integrated with single-cell host transcriptomics to profile intratumoral microbiota and construct microbial-immune interaction networks in five HCC tumors and paired adjacent normal tissues. Peritumoral microbiome analysis was conducted using 2b-Rad-M sequencing. Through systematic bacterial isolation (LB/Columbia/BCSA/Schaedler media) and Sanger sequencing validation, Pseudomonas koreensis (P.K) was identified as a key HCC-associated strain. Spatial localization and ultrastructural characterization were achieved via fluorescence in situ hybridization (FISH), multiplex fluorescence staining, and electron microscopy. Whole-genome sequencing delineated its genomic architecture, while metabolomics uncovered unique metabolic signatures. Functional validation using orthotopic HCC models (MYC/Alb and NSG mice) revealed its pro-tumorigenic role and immunomodulatory effects.

Results

2b-Rad-M sequencing showed significantly higher abundance of Bacillus, Pseudomonas, and Klebsiella in HCC tissues compared to adjacent non-tumor tissues, with reduced bacterial diversity. Circos plots highlighted increased Proteobacteria and Firmicutes in HCC. Through culturing and Sanger sequencing, P.K was identified as a dominant strain in HCC, showing quinolone sensitivity and urease activity. FISH confirmed its widespread presence in HCC tissues, with elevated abundance in T cells from advanced-stage patients. INVADE-seq analysis of five additional HCC tissue pairs also detected P.K Single-cell INVADE-seq revealed that T cells harboring this bacterium exhibited increased exhaustion scores and upregulated TOX expression. In MYC/Alb mice, oral gavage of P.K accelerated hepatocarcinogenesis, but no significant effect was observed in NSG immunodeficient mice, indicating immune system dependency. Whole-genome sequencing linked HCC-derived P.K to the fish pathogen P. koreensis CM-01, with enriched amino acid and carbon metabolism pathways. Metabolomics analysis associated it with purine/pyrimidine metabolism and cGMP-PKG signaling. Reduced spermidine levels impaired fatty acid oxidation, exacerbated T cell exhaustion, and promoted an immunosuppressive microenvironment, enhancing tumor proliferation, invasion, and metastasis.

Conclusion

This study reveals how intratumoral microbiota regulate the tumor microenvironment via the metabolism-immune axis, offering new insights into HCC immunotherapy. Targeting P.K-related metabolic pathways may provide a novel therapeutic strategy.

Disclosure

The authors declare no conflict of interest.

Introduction

Pancreatic necrosis is a devastating disease that leads to a high mortality and morbidity rates. Necrosectomy is the golf standart treatment for infected pancreatic necrosis. Percutaneous and endoscopic approaches has been widely accepted in selected cases. Endoscopic necrosectomy in early complicated pancreatic necrosis were performed as a first intent to treat and retrospectively evaluated regarding to morbidity, efficacy, recurrence and length of hospital stay.

Aims & Methods

Report our experience on endoscopic manage of pancreatic necrosis using a daily transmural and transpapillary drainage in 25 patients.
Records of all patients who underwent EN from January 2023 to January 2025 Endoscopic manage of acute pancreatic necrosis using a daily transmural and transpapillary drainage in 25 patients. The Apache classification and CCT score is used. Diagnostic ERP to search communications between pancreatic duct and the collection were performed in selective cases and in cases that communication exists; prothesis can be inserted through the minor or major papilla to plug it. The transmural drainage was performed in 25 patients (05 Duodenal and 20 gastric) and transpapillary and transmural in 07 patients, after identification of the most proeminent or bulging part of the stomach or duodenum. All patients were followed with CT scans, IRM to ensure clinical resolution.

Results

25 patients (14 women, 09 men) could be treated. The Apache classification is used 0 a 9 score in 14 patients (56,%) and 11 (44%), CT severity index was 30-50% in 05, > 50% in 20. Pancreatic necrosis were located in the pancreatic head in 03 patients, the head/body in 02, body in 6, body/tail 04, head/body/tail 10. ERP demonstrated the ductal communication of the colection with the main pancreatic duct in 07 patients, rupture in 03, disconnect syndrome in 03 and normal in 02. Drainage was successful in 25 (100%). 07 (28%) combined treatment (transpapillary and transmural), 18 (72%) transmural. The median number of endoscopic session for each patients was 4 (range 2 to 8). The median hospital stay for in the all patients was only endoscopic therapy was 9. The range follow –up was 18 months (range 6 to 24) with mean number of ERCPs was 4 (range 2 to 8). Two patients required concurrent radiology procedure, recurrence of fluid collection (n=1), flank abscess (n=1). There were 2 (16,6%) pseudocyst recurrences during this period, and were managed clinically and/or endoscopically. There was no mortality related to the procedure.

Conclusion

The early and aggressive endoscopic treatment with daily necrosectomy can be performed and show promising results same in early complications of pancreatic necrosis. Combined approaches with radiology and conventional surgery can also be applied in selected cases.

Disclosure

No Conflict of Interest

Introduction

ESD allows en bloc resection of complex colorectal polyps. General anaesthetic (GA) for ESD is standard, requiring routine admission to hospital for monitoring. At our Trust conscious sedation is used preferentially. This study presents clinical outcomes of ESD performed in a high-volume tertiary centre in the UK using this approach.

Aims & Methods

• To evaluate the clinical outcomes of colorectal endoscopic submucosal dissection performed without general anaesthesia in a high-volume UK tertiary centre.
• To assess the feasibility and safety of ESD under conscious sedation or no sedation, with particular focus on rates of en bloc and R0 resection, adverse events, and post-procedural admissions.
• To identify clinical and procedural factors independently associated with incomplete (R1) resection following colorectal ESD.
• To compare outcomes between patients undergoing ESD with GA versus those without
Colorectal ESD procedures performed between 2018-2024 in a single centre in the UK were included. Data was retrospectively collected from the patient records. Multiple logistic regression was performed to identify independent factors associated with incomplete resection.

Results

A total of 147 patients (91 males ; median age 68 years) were included. Most polyps were rectal (100/150, 66.6%). Median polyp diameter was 42.5 mm.
GA was utilised in 13 patients, 80 had sedation alongside analgesia (median dose midazolam=2mg, fentanyl=100mcg) 44 required no IV sedation or analgesia, 8 had analgesia alone (median dose fentanyl 100mcg), 2 had sedation alone (median dose midazolam 0.75mg).
4 patients were admitted to hospital after their procedure and 14 were admitted within 30 days. There were 4 (2.7%) perforations and 7 (4.7%) post polypectomy bleeds (PPB).
Most procedures were complete ESD (109/147, 74.1%), the rest being hybrid ESD. R0 excision was achieved in 70/109 (64.2%) of those who had a complete ESD resection. No residual tissue was seen in patients with an R0 resection who had a subsequent LGI endoscopy (43/70). In those with R1 resection, a site check was undertaken at the same Trust in 59 patients. Residual tissue was seen in 7/59 (12%).
On univariate binomial regression, R1 resection was associated with polyps involving the dentate line [OR = 5.29 (95% CI = 1.84 – 17.8)], those with severe fibrosis [OR = 20.8 (95% CI = 3.85- 386.4)] and those receiving a GA [OR = 3.56 (95% CI = 1.06-16.3)]. On multivariate analysis, polyps involving the dentate line [OR = 8.17 (95% CI = 2.24 – 35.8)] and those with severe fibrosis [OR = 17.9 (95% CI = 2.57- 366.2)].

Table 1 - Outcomes of admissions following ESD

Conclusion

ESD is an effective treatment for high-risk complex colorectal polyps, able to provide high rates of en bloc resection. It can be achieved safely in most patients without GA. GA was associated with a higher rate of R1, however, this likely relates to these lesions being more complex.

Clinical Case Summary

A 46-year-old man from Bolivia consulted for abdominal pain with watery diarrhoea and occasional rectorrhagia for the last 2 months, associated with asthenia and weight loss. Laboratory tests showed microcytic anaemia, elevated C-reactive protein, positive faecal occult blood and negative stool culture. Colonoscopy (Images 1, 2) revealed deep ulcers in the ileum and colon with discontinuous areas of respected mucosa. Treatment was started with oral methylprednisolone at a dose of 1 mg/kg, with a decrease in the stool rhythm. He returned to the emergency department due to worsening abdominal pain, and was admitted for follow-up care. Histology (Image 3) showed epithelioid granulomas of probable infectious origin, due to the intramacrophagic inclusions, so the corticosteroid treatment was suspended. The quick test for HIV was positive, with a viral load of 79,000 copies/ml and a CD4 count of 88 CD4/ml. Mantoux and IGRA were negative. PCR amplification for Histoplasma spp in ileal biopsy was positive. Amphotericin B was prescribed with prophylaxis of opportunistic infections with trimethoprim-sulfamethoxazole. After 2 weeks, antiretroviral treatment was started. The patient improved, the abdominal pain disappeared and his intestinal rhythm normalised, and he was discharged from hospital. On outpatient follow-up, he was asymptomatic, with resolution of the ulcers in the control colonoscopy and no evidence of fungal structures in the histological examination.
The infection by Histoplasma capsulatum is the most frequent endemic mycosis in the American continent. Intestinal involvement is rare, with a preference for the ileocecal region in the form of deep ulcers that can simulate an outbreak of Crohn disease, as in our case. The use of immunosuppressants, especially anti-TNF-alpha, may worsen its course, highlighting the importance of a broad differential diagnosis, taking into account the patient's epidemiological characteristics.

References

Image 1. Colonoscopy. Terminal ileum with large ulcer with fibrin background, oedema and perilesional erythema.
Image 2. Colonoscopy. Transverse colon with two large deep ulcers with fibrin background and raised edges.
Image 3. Biopsy of ileum. Non-caseating epithelioid granulomas with intramacrophagic inclusions in ileal tissue. HE 40x.

Introduction

Sessile serrated lesions (SSLs), alongside adenomas, play a significant role in the development of colorectal cancer (CRC). Recent studies suggest that the adenoma detection rate (ADR) alone may not be sufficient for predicting post-colonoscopy CRC. Consequently, the ASGE/ACG Quality Task Force has recently recommended the sessile serrated lesion detection rate (SSLDR) as a new priority indicator for colonoscopy quality. Reviewing the variability of SSLDR in the control groups of previous randomized controlled trials (RCTs) may help identify factors that influence study outcomes.

Aims & Methods

A systematic review was conducted using PubMed, Embase, and the Cochrane Library databases to collect data from control groups of RCTs that assessed methods for increasing polyp detection with high-definition white-light colonoscopy (up to March 14, 2025). Random-effects meta-analysis pooled SSLDRs and their 95% confidence intervals (CIs). Heterogeneity was assessed with the I² statistic. Univariable and multivariable meta-regressions were performed to examine associations between SSLDR and study settings (publication year, sample size, number of centers, study design, and geographic origin), demographics (mean age, male proportion), and technical parameters (type of intervention, proportion of screening colonoscopy, ADR, and withdrawal time). This study was registered in PROSPERO (ID: CRD420251012475).

Results

A total of 23,461 patients from 48 studies were included in the analysis. SSLDR in the control arms ranged from 0.3% to 21.5%, with a pooled value of 4.4% (95% CI: 3.3%-5.8%; I² = 93%). Univariable meta-regression analysis identified patient age (OR 1.112; 95% CI: 1.043-1.186) and gender (OR 1.038; 95% CI: 1.003 to 1.074), geographic origin (OR 2.848; 95% CI: 1.585-5.116 for Europe and OR 4.044; 95% CI: 2.205-7.416 for North America), and ADR in the control arms (OR 1.054; 95% CI: 1.031-1.077) as significant predictors of SSLDR, with sample size (OR 0.999; 95% CI: 0.998-1.000) showing a negative correlation. Other factors, such as publication year, number of study centers (single or multiple), study design (parallel or tandem), type of intervention (imaging or mechanical), proportion of screening colonoscopy, and withdrawal time, had no significant effect. In multivariable meta-regression, RCTs conducted in Europe (OR 2.179; 95% CI: 1.242-3.820) and North America (OR 2.664; 95% CI: 1.550-4.580), as well as ADR in control arms (OR 1.035; 95% CI: 1.006-1.065), remained significant predictors of SSLDR, while sample size (OR 0.998; 95% CI: 0.997-0.999) and proportion of screening colonoscopy (OR 0.991; 95% CI: 0.983-0.998) were negatively correlated with SSLDR.

Conclusion

A high level of variability in SSLDR was found in the control groups of RCTs. Standardization of methodological and technical parameters is essential to improve the generalizability and reproducibility of findings from RCTs and enhance SSL detection in colonoscopy.