Introduction

Withdrawal time (WT) is strongly correlated with adenoma detection rate (ADR)^1,2. Corrected withdrawal time (cWT), defined as the withdrawal time excluding periods spent on therapeutic interventions, provides a more accurate measure of mucosal inspection effort. Optimal WT targets may differ between staff and trainee endoscopists due to differences in experience and inspection technique³.

Aims & Methods

We aimed to determine the cWT required to achieve ADR benchmarks (≥35%) and compare detection metrics between these two groups.
This prospective study included 1,439 elective colonoscopies of adult patients ≥18 years, performed at Montreal University Hospital Center: 397 by eight supervised trainees and 1,042 by 12 staff endoscopists. All procedures were video recorded, and the corresponding meta-data were documented in real-time by a research assistant present in the endoscopy room. Procedures performed for the purpose of polypectomy, incomplete colonoscopies, procedures performed by endoscopists with experience of fewer than 10 colonoscopies, and procedures with technical failures in recording that prevented video analysis were excluded. Colonoscopy videos were reviewed to precisely measure cWT, defined as total withdrawal time minus therapeutic intervention durations. Performance metrics were stratified by endoscopist training level (staff vs trainees). Primary outcome was the mean cWT required to achieve ADR ≥35%, stratified by staff and trainees. Secondary outcomes were the mean per-lesion intervention time, ADR, advanced ADR (AADR), Serrated Lesion detection rate (SLDR), APC, and the incremental increase of all detection measures per minute of cWT compared between staff and trainees, adjusting for covariates including patient demographics, bowel preparation quality, indication for colonoscopy, use of computer-assisted detection, and clustering by individual endoscopist using generalized estimating equations (GEEs).

Results

Trainees demonstrated significantly longer mean cWT than staffs (10’01’’ vs 7’53’’, p<0.001). No significant difference was observed regarding mean per-polyp intervention time (1′33″ vs 1′28″, p=0.234). On average, staff endoscopists required longer mean cWT to achieve the 35% ADR benchmark compared to trainees (9'47'' [95% CI: 8'04''-12'20''] vs. 7'05'' [95% CI: 0'00''-10'05'']). Overall AADR, SSLDR, and APC were significantly higher for trainees than staff (Table 1; AADR 10.8% vs. 5.3%; SSLDR 8.1% vs 3.6%; APC 0.8 vs 0.6). Overall, the odds of adenoma detection significantly increased with each additional cWT minute for both trainees and staffs (Table 1; 6.6% overall, 6.7% for staff, and 7.0% for trainees).

Table 1. Metrics’ estimated summaries overall and by endoscopist group. Means and 95% confidence interval (CI) are raw estimates. Percent increases and corresponding p-values arise from GEEs.

Conclusion

Trainees had longer cWT and higher detection rates overall, while staff required slightly more cWT to reach ADR target of ≥35%. These findings emphasize the importance of tailored WT benchmarks based on endoscopist training level to optimize colonoscopy quality and training outcomes.

References

1. Barclay RL, Vicari JJ, Doughty AS, Johanson JF, Greenlaw RL. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med. 2006;355(24):2533–2541. doi:10.1056/NEJMoa060884

2. Zhao S, Wang S, Pan P, et al. Magnitude, risk factors, and factors associated with adenoma miss rate of tandem colonoscopy: a systematic review and meta-analysis. Gastroenterology. 2019;156(6):1661–1674.e11. doi:10.1053/j.gastro.2019.01.265

3. Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2006;63(4 Suppl):S16–S28. doi:10.1016/j.gie.2006.02.021

Disclosure

Daniel von Renteln has received research funding from ERBE Elektromedizin GmbH, Ventage, Pendopharm, Fujifilm, and Pentax, and has received consultant or speaker fees from Boston Scientific Inc., ERBE Elektromedizin GmbH, and Pendopharm. Roupen Djinbachian has received speaker fees from Fujifilm. The remaining authors declare that they have no conflict of interest.

Clinical Case Summary

A 58 year-old woman was admitted for an elective rectosigmoidectomy after two previous uncomplicated diverticulitis episodes. On the third postoperative day, her clinical status deteriorated, and an abdominal CT scan revealed an anastomotic leak, leading to a new surgery and confection of a protective ileostomy. Her condition improved progressively, and she was discharged 10 days after. However, the patient came back to the emergency one week later with abdominal pain, fatigue, and refractory nausea and vomiting, in addition to acute renal failure with severe hyponatremia and hyperkalemia. Because her daily ileostomy’s output reached about 2 liters/day, she was started on high dose opioids and loperamide to decrease the stoma’s output, as well as replacement fluid therapy, improving quickly within 24 to 48 hours. She was discharged in 5 days.
Despite the adequate control of the ileostomy’s output, her second readmission occurred 12 days later, showing the same clinical and laboratorial patterns. Considering she had a typical profile for adrenal insufficiency, fludrocortisone was associated with the antimotility agents, showing a significant improvement within hours. Nonetheless, she discontinued fludrocortisone on her own, and a third readmission occurred in 10. One more time, clinical and laboratorial characteristics were the same, with rapid improvement in the short term. An extensive investigation was conducted, revealing an aldosterone level more than 10 times higher than upper limit of normal, with normal renin levels and an adrenocorticotropic hormone in the lower limit of normal. These paradoxical findings were reinforced with a low urine and high ileostomy sodium dosages, and a diagnosis of a type 3 pseudohypoaldosteronism was made. Definitive treatment with intestinal transit’s reconstruction was performed, with complete resolution.

References

1. Carl C, Dinkelbach L, Mohr J, Perez R, Vera Lopez T, Fricke-Otto S, Niehues T. Case report: Life threatening hyponatremia in infants with urinary tract infections: two cases of type III pseudohypoaldosteronism and review of the literature. Front Pediatr. 2024 Jan 5;11:1233205. doi: 10.3389/fped.2023.1233205. PMID: 38250595; PMCID: PMC10797885.
2. Amir Babiker, Haya Aldabas, Shahad Alanazi, Bashayer Alahmadi, Waleed Tamimi, Mohsen Al Atawi, Fahad Aljuraibah, Angham Almutair. Pseudohypoaldosteronism: A challenging diagnosis with management pitfalls - Case series. Journal of Clinical and Translational Endocrinology: Case Reports, Volume 32, 2024, 100172. ISSN 2214-6245
3. Stojanović, V., Spasojević, S., Radovanović, T., & Doronjski, A. (2017). Pseudohypoaldosteronism: report of three cases. Journal of Endocrinology, Metabolism and Diabetes of South Africa, 22(2), 17–20. https://doi.org/10.1080/16089677.2017.1335532
4. Nakasone, Ruka et al. Three cases of pseudohypoaldosteronism following ileostomy in preterm infants. Pediatrics & Neonatology, Volume 62, Issue 1, 119 - 121

Introduction

Eosinophilic oesophagitis [EoE] is a chronic, antigen-driven, immune-mediated oesophageal disease characterised by eosinophil-predominant inflammation. It typically presents with dysphagia, food bolus impaction, and, in children, feeding difficulties and failure to thrive [1]. Histologically, it is defined by ≥15 eosinophils per high-power field on oesophageal biopsy in the absence of other causes of eosinophilia [2]. The incidence and prevalence of EoE have increased markedly over recent decades, particularly in Western countries, likely due to increased recognition, changing environmental exposures, and altered microbiota [3,4]. Though EoE is increasingly reported worldwide, data specific to Aotearoa New Zealand, and especially regional patterns by ethnicity, remain limited.

Aims & Methods

This study aimed to describe the incidence, demographic distribution, and clinical characteristics of EoE in the Canterbury region over an 11-year period.
We conducted a retrospective analysis of electronic medical records from 2013 to 2023, identifying EoE cases using diagnostic codes and histological confirmation. Demographic data, clinical presentations, and laboratory findings were collected. Crude incidence rates were calculated using average population data for the Canterbury region, stratified by ethnicity (European vs. non-European). Clinical features including food bolus obstruction, oesophageal strictures, and peripheral eosinophilia were assessed. Incidence rates are reported per 100,000 population with 95% confidence intervals (CI).

Results

A total of 219 cases of EoE were identified between 2013 and 2023. The average annual incidence was 3.23 per 100,000 population (95% CI: 1.82–4.65), based on a regional population of 618,409. The mean number of cases per year was 20 (IQR 16–22). Among European individuals (average population 395,690), the mean annual incidence was 4.42 per 100,000 (95% CI: 2.35–6.49), with 17.5 average cases per year (IQR 14–21). Among non-European individuals (average population 222,627), the mean incidence was 1.08 per 100,000 (95% CI: -0.29–2.44), with 2.4 average cases per year (IQR 1–4).
Of the 219 cases, 70 patients (31.9%) presented with oesophageal food bolus impaction. The annual number of such presentations ranged from 3 to 12 per year (median 6, IQR 4–9). Twenty patients (9.1%) had documented stricturing disease on endoscopy, and 60 patients (27.4%) exhibited peripheral eosinophilia at diagnosis.

Conclusion

In our cohort, eosinophilic oesophagitis presents commonly with oesophageal food bolus impaction. There was a higher incidence of EoE observed in individuals of European descent. Just under one-third of patients in our cohort presented with oesophageal food bolus impaction and about 9% had stricturing disease. The frequent presentation with food bolus obstruction and the presence of complications such as strictures highlight the importance of timely recognition and management. Peripheral eosinophilia was found commonly in our cohort but the prevalence of this finding is not adequate to be used as a diagnostic test in EoE, although more studies are needed.

References

1. Dellon ES, Liacouras CA, Molina-Infante J, et al. Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference. Gastroenterology. 2018;155(4):1022-1033.e10.
2. Lucendo AJ, Molina-Infante J, Arias Á, et al. Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults. United European Gastroenterol J. 2017;5(3):335-358.
3. Hruz P, Straumann A, Bussmann C, et al. Escalating incidence of eosinophilic esophagitis: A 20-year prospective, population-based study in Olten County, Switzerland. J Allergy Clin Immunol. 2011;128(6):1349-1350.e5.
4. Arias Á, Lucendo AJ. Epidemiology and risk factors for eosinophilic esophagitis: Lessons for clinicians. Expert Rev Gastroenterol Hepatol. 2020;14(2):103–115.

Disclosure

None

Introduction

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an effective treatment for patients in whom transpapillary biliary drainage fails. However, EUS-HGS is associated with a high incidence of early procedure-relatedadverse events (PRAEs) due to bile leakage through a biliogastrointestinal fistula.

Aims & Methods

This multicenter study retrospectively evaluated the clinical outcomes of EUS-HGS. This study included 222 patients (120 men, 102 women; median age, 73 years) who underwent initial EUS-HGS between November 2014 and August 2024. Technical and clinical success rates, PRAEs, and stent dysfunction rates were analyzed. PRAEs were defined as adverse events occurring within 2 weeks according to the assessment of the American Society for Gastrointestinal Endoscopy.

Results

Benign and malignant tumors were observed in 18 (8.1%) and 204 (91.9%) patients, respectively. The median procedure time for EUS-HGS was 41 min (range, 11–173 minutes). Plastic and metal stents were deployed in 51.4% and 48.6% of the patients, respectively. Technical and clinical success rates and PRAEs were 97.8%, 85.1%, and 22.1%, respectively. The PRAEs were classified into mild (16.7%), moderate (4.1%), or severe (1.4%). Recurrent biliary obstruction (RBO) occurred in 51 (23.1%) patients. The median time to RBO in the metal stent group was significantly longer than that in the plastic stent group (313 vs. 162 days, P=0.02). Multivariate analysis identified the use of any dilation device (P=0.01; odds ratio [OR]: 3.55; 95% confidence interval [CI]: 1.35–9.36) and concomitant antegrade stenting (P=0.03; OR: 2.62; 95% CI: 1.12–6.12) as risk factors for PRAEs.

Conclusion

EUS-HGS is feasible; however, careful follow-up is required for patients undergoing fistula dilation and concomitant antegrade stenting.

Introduction

Lynch syndrome (LS), the most common hereditary colorectal cancer (CRC) syndrome, is associated with an increased risk of small bowel malignancies. Given the feasibility of ileal intubation during colonoscopy, this study assesses the prevalence of ileal cancer in a large LS cohort and evaluates ileal intubation as a screening tool.

Aims & Methods

An analysis was performed on Lynch syndrome (LS) patients with ileal cancer enrolled in the prospectively maintained database of the German Consortium for Familial Intestinal Cancer (GCFIC). Demographic characteristics and cancer history were extracted. High-risk pathogenic germline variants (PGVs) were defined as MLH1, MSH2, and EPCAM, while MSH6 and PMS2 were considered low risk.
Additionally, data from 236 LS patients who underwent colonoscopy at a tertiary care center between 2018 and 2023 were retrospectively evaluated. A total of 596 complete colonoscopies were reviewed.

Results

Eight ileal cancers (0.28%) were identified, exclusively in high-risk PGV carriers (MLH1: 62.5%, MSH2: 37.5%), predominantly male (87.5%), with a median age of 56 years. Most cancers (75%) were symptom-detected; only one case was identified through screening. In the tertiary care cohort, ileal intubation was achieved in 96.6% of colonoscopies, leading to the identification of five ileal neoplasms (four adenomas, one carcinoma), all in patients with a history of right hemicolectomy or colectomy. The prevalence of ileal neoplasia in patients without an ileocecal valve was statistically significant at 7.7% (χ²(1, N = 236) = 11.8, p < .001).

Table 1: Cohort characteristics of the German Consortium for Familial Intestinal Cancer

Conclusion

Ileal intubation is a valuable extension of standard colonoscopy, especially for male high-risk PGV carriers with prior CRC and ileocecal valve removal. The strong link between ileal neoplasia and loss of the ileocecal valve suggests a role for colonic reflux, inflammation, and microbiome changes in ileal carcinogenesis.

Disclosure

Robert Hüneburg was funded by Deutsche Krebshilfe (DECADE), and Wilhelm-Sander-Stiftung.
Jacob Nattermann was funded by Wilhelm-Sander-Stiftung.

Introduction

Malignant biliary obstruction (MBO) caused by non-hepatobiliary-pancreatic (non-HBP) malignancies is a rare and underexplored indication for endoscopic retrograde cholangiopancreatography (ERCP). These cases often present a clinical dilemma: while ERCP offers a minimally invasive option, its utility remains uncertain in patients with poor prognosis and advanced disease.

Aims & Methods

We aimed to evaluate the effectiveness of ERCP-guided biliary drainage in this context and identify baseline predictors of clinical failure to help refine patient selection.
We conducted a retrospective analysis of all patients who underwent ERCP for malignant biliary obstruction of non-HBP origin between March 2018 and February 2025. Patients lacking essential clinical or follow-up data were excluded. Technical success was defined as adequate stent placement; clinical success as a ≥50% reduction in bilirubin or resolution of cholangitis within 2 weeks. The predictive role of bilirubin level, stricture location, serum albumin, and ECOG performance status was assessed. A ROC analysis evaluated the discriminative ability of pre-drainage bilirubin.

Results

Forty-eight patients were included (mean age: 55.6 years; 56% women). The most common primary cancers were colorectal (31%, n=15), gastric (18%, n=9), breast (14%, n=7), lung (10%, n=5), and ovarian (8%, n=4). Hilar strictures were observed in 54% (n=26) and mid-to-distal strictures in 46% (n=22). All procedures were performed using plastic stents. In most cases involving hilar strictures, long stents (e.g., 7 Fr / 12–15 cm) were used, and a single biliary sector—usually the most dilated or invaded—was preferentially drained. Technical success was achieved in 85.4% of cases. Clinical success occurred in 54.1% of patients, while early mortality (≤30 days) reached 10.4%, exclusively among individuals with ECOG status 4 and serum albumin <2.8 g/dL. Hilar strictures and total bilirubin levels >200 mg/L were significantly associated with lower clinical success rates (38% vs 65%, p=0.03 and 33% vs 62%, p=0.04, respectively). ROC analysis showed an AUC of 0.72 for bilirubin in predicting failure. Technical failures (14.6%) were mainly due to anatomical distortion or papillary inaccessibility.

Conclusion

Endoscopic biliary drainage in this population is technically achievable but offers limited clinical benefit, especially in cases with hilar involvement, severe hyperbilirubinemia, or poor overall condition. These findings emphasize the importance of using simple, baseline clinical indicators to guide treatment decisions, avoid unnecessary interventions, and adapt care strategies to the realities of resource-limited settings.

Disclosure

I have no conflict of interest.

Introduction

Accurate prediction of lymph node metastasis (LNM) in submucosal invasive (T1) colorectal cancer (CRC) is essential for determining the need for additional surgery following endoscopic resection. Conventional histopathological assessments, however, are limited by interobserver variability. This study aimed to develop and externally validate a stacking-based artificial intelligence (AI) model integrating histopathological whole slide images (WSIs) and clinical parameters to predict the risk of LNM in T1 CRC.

Aims & Methods

This retrospective study included 1,056 patients with histologically confirmed T1 CRC treated at Showa Medical University Northern Yokohama Hospital. Of these, 593 cases were used for model training and 100 for internal testing. External validation was conducted on 25 cases from two independent institutions.
The proposed stacking ensemble model incorporated the Multiple Instance Self-Training (MIST) score derived from WSIs, patient sex, and tumor location (colon vs. rectum). Base learners included logistic regression, XGBoost, and random forest, with a meta-learner synthesizing their outputs to generate the final LNM prediction. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) in both internal and external cohorts.

Results

LNM was observed in 69 (11.6%) training cases, 15 (15.0%) test cases, and 2 (8.0%) external validation cases. The model achieved an AUC of 0.6965 in the internal test cohort and 0.7500 in the external validation cohort, demonstrating stable and generalizable predictive performance.
A representative case involved a 64-year-old man with a 16-mm type 0-Is lesion in the sigmoid colon resected via endoscopic mucosal resection (EMR). Histopathology showed well-differentiated tubular adenocarcinoma (tub1 > tub2), submucosal invasion depth of 3,300 µm (T1b), tumor budding grade BD1, Ly0, V1a, and negative resection margins (HM0, VM0). Despite guideline-based recommendations prompting additional surgical resection, no LNM was found (N0, 0/16), and the patient remained recurrence-free five years postoperatively—consistent with the AI model’s prediction.

Conclusion

The stacking-based AI model exhibited robust and generalizable performance in predicting LNM in T1 CRC, both internally and across external institutions. This approach offers a complementary tool to conventional pathology and may enhance individualized decision-making regarding the necessity of additional surgical intervention.