Clinical Case Summary

A 54-year-old male with chronic myeloid leukemia (CML) diagnosed in May 2015, on Imatinib since April 2023, presented in October 2024 a severe anemia (Hb 5.2 g/dL [13-17]). Investigations done at that time, including bone marrow analysis, hemolysis workup and a FIT test were normal. An abdominal CT scan was also done at that time and was also normal.. In December 2024, the patient reported two weeks of melena. A bidirectionnel endoscopy didn’t show any lesion. CT scan revealed hepatomegaly and gallstones, without any GI mass.
Video capsule endoscopy showed active jejunal bleeding without being able to identify the underneath lesion. Enteroscopy revealed two ulcerated jejunal lesions of around 2 cm in diameter with an adherent clot, one meter from the papilla, [Figure 1,2]. Surgical resection was then performed [Figure 3]. Histology confirmed epithelioid angiosarcoma with submucosal infiltration, numerous mitoses, endolymphatic tumor emboli, and ERG+, cytokeratine AE1/AE3+ immunoprofile. Resection margins were clear; 0/3 lymph nodes were involved. [Figure 4a-b-c-d] As part of the metastatic workup, brain MRI showed multiple cerebral metastases.
Following the diagnosis, the treatment plan consisted of paclitaxel in combination with bevacizumab (Avastin).
This case illustrates the diagnostic challenge of unexplained anemia in hematologic patients, particularly when standard evaluations fail to identify a clear cause. In this instance, gastrointestinal bleeding ultimately revealed a rare small bowel malignant lesion—epithelioid angiosarcoma. While epithelioid angiosarcoma has no established association with chronic myeloid leukemia (CML) or its treatment, it is worth noting that the use of tyrosine kinase inhibitors may obscure the clinical presentation of angiosarcoma. This is due to their antiangiogenic effects, which can alter vascular structures and potentially delay diagnosis. Therefore, high clinical suspicion remains essential.

References

Figure 1,2 : Enteroscopy revealing ulcerated jejunal lesion with an adherent clot. Images obtained during enteroscopy performed at Hôtel-Dieu de France University Hospital, Beirut, Lebanon.
Figure 3 : Resected jejunal segment showing two hemorrhagic polypoid tumors, one marked with a hemostatic clip. The lesions correspond to an ulcerated angiosarcoma. Image obtained post-surgical resection at Hôtel-Dieu de France University Hospital, Beirut, Lebanon.
Figure 4a : Histological appearance of epithelioid angiosarcoma H&E stain, high magnification
Figure 4b : Histological appearance of epithelioid angiosarcoma H&E stain, intermediate magnification
Figure 4c : Histological appearance of epithelioid angiosarcoma H&E stain, low magnification
Figure 4d : Histological appearance of epithelioid angiosarcoma ERG nuclear immunostain, intermediate magnification
Figure 4e : Histological appearance of epithelioid angiosarcoma Cytokeratin AE1/AE3 immunostain, intermediate magnification

Introduction

Hirschsprung’s disease is caused by the absence of ganglia in the deep intestinal wall, leading to dysfunction [1]. Resection of the affected area is the only cure, so accurate margin detection is essential. Currently, intraoperative rapid pathology is used, requiring tissue sampling and staining, but each test takes over 30 min and may need multiple samples, sometimes delaying decisions up to 3 h. A quick on-site method to detect ganglia around 200 μm deep is needed.
Various methods, including confocal microscopy [2], have been studied, but issues remain, such as dye toxicity and limited depth (>200 μm) imaging.

Aims & Methods

For non-destructive and stain-free visualization of tissues, we focused on Near-Infrared Hyperspectral Imaging (NIR-HSI)[3][4]. Near-infrared light—particularly in the 1000–1400 nm range—exhibits high tissue penetrability and is effective for detecting deep tissues. In addition, the near-infrared region provides spectroscopic information based on molecular vibrations, enabling component analysis. NIR-HSI holds promise for the identification of cancer and other biological tissues without the need for fluorescence or external marking [4][5].
To implement NIR-HSI, we developed a novel microscopic optical system capable of guiding near-infrared light. The near-infrared light source, which combines a supercontinuum light source and an acousto-optic tunable filter, allows for the selection of arbitrary wavelengths and irradiation of the target by adjusting the applied voltage [6]. This configuration enables the acquisition of near-infrared spectral images (NIR-HSI) at arbitrary wavelengths.
For performance validation, ex vivo experiments were carried out using mouse intestine in which the nerve plexus was selectively labeled with GFP (Green Fluorescent Protein). In these experiments, near-infrared light ranging from 850 to 1400 nm was irradiated in 10-nm increments, and 77 spectral images were captured. As a reference, GFP fluorescence images were acquired in the same field of view as the near-infrared images. Based on the fluorescence images, annotations were performed to delineate the enteric nerve plexus, and near-infrared spectra were obtained from both the nerve and non-nerve regions. Furthermore, using pixel-wise spectral data, segmentation of the nerve regions was performed with a machine learning model, and the accuracy of identification was evaluated.

Results

The NIR images captured by the system showed nerve distributions and mesh-like patterns similar to those in the GFP images. Spectral differences were observed between nerve and non-nerve regions. This likely reflects tissue composition differences, as muscle tissue has higher transmittance and nerve tissue higher reflectance in the NIR range [4][5][6].
Segmentation based on spectral data successfully extracted nerve contours and distribution patterns, achieving ~80% classification accuracy.

Conclusion

To enable non-invasive, label-free visualization of deep nerve distributions, we developed a NIR-HSI microscope by integrating near-infrared hyperspectral imaging with a microscopic optical system. In mouse intestine experiments, spectral differences were observed between enteric nerve plexus and surrounding tissue. The results suggest that mesh-like nerve structures can be estimated and outlined using NIR images alone. Future work will focus on imaging human samples.

References

1. Taguchi, T.et al., “The incidence and outcome of allied disorders of Hirschsprung's disease in Japan: Results from a nationwide survey,” Asian Journal of Surgery, vol.40-1, pp.29-34, 2017.
2. Kobayashi, M., Sumiyama, K., Shimojima, N., Ieiri, S., Okano, H., Kamba, S., Fujimura, T., Hirobe, S., Kuroda, T. and Takahashi‐Fujigasaki, J., “Technical Feasibility of Visualizing Myenteric Plexus Using Confocal Laser Endomicroscopy,” Journal of Gastroenterology and Hepatology, vol.32(9), pp.1604-10, 2017.
3. S. Hayashi et al., “Near-Infrared Multispectral Imaging Rigid Endoscope System for High-Speed Target Identification Using LED Rotating Light Source”, Advanced Biomedical Engineering , Vol.14, pp.79-88, 2025.
4. Akbari, H et al., “Cancer detection using infrared hyperspectral imaging”, Cancer Science, Vol. 102, No.4, pp.852–857, 2011
5. Afromowitz,et al., “Multispectral imaging of burn wounds: a new clinical instrument for evaluating burn depth”, IEEE Transactions on Biomedical Engineering, Vol35, No.10, pp.842-850, 1988.
6. R. Fukushima et al., “Detection of Exposed Nerves in Two Individuals In Vivo and Unexposed Nerves Ex Vivo with Near-Infrared Hyperspectral Laparoscope,” 2024IEEE/SICE International Symposium on System Integration (SII), Ha Long, Vietnam, pp. 19-24, 2024.

Introduction

Endoscopic resection techniques, such as Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD), are used to remove precancerous and early-stage cancerous lesions in the gastrointestinal tract. While ESD is the gold standard due to its en-bloc and R0 resection capability, Underwater Endoscopic Mucosal Resection (UEMR) has emerged as an alternative. UEMR uses water buoyancy to aid lesion resection, potentially improving safety and reducing procedure time. However, its comparative effectiveness remains unclear.

Aims & Methods

The primary aim of this systematic review and meta-analysis is to compare the efficacy, safety, and procedural efficiency of Underwater Endoscopic Mucosal Resection (UEMR) versus Endoscopic Submucosal Dissection (ESD) in the treatment of gastrointestinal lesions.
A systematic search was conducted in PubMed, Embase, Google Scholar, Scopus, and Cochrane Library. Eligible studies compared UEMR and ESD in gastrointestinal lesions, providing data on en-bloc resection, R0 resections, adverse events, and procedure time. Randomized controlled trials (RCTs), cohort studies, and comparative studies were included.
Two reviewers independently extracted data, resolving discrepancies by discussion. Study quality was assessed using the Cochrane Risk of Bias Tool. Random-effects models were used for pooled analyses, calculating odds ratios (OR) and mean differences with 95% confidence intervals (CI). Heterogeneity was evaluated via the I² statistic.

Results

The analysis included four studies (three RCTs and one cohort study), with a total of 651 patients. Regarding efficacy, UEMR showed significantly lower en-bloc resection rates compared to ESD (OR = 0.01, 95% CI [0.01–0.06], Z = 6.85, p < 0.00001), suggesting a reduced ability to achieve complete lesion removal in a single piece. Similarly, R0 resection rates were also lower in the UEMR group (OR = 0.16, 95% CI [0.09–0.22], Z = 9.09, p < 0.0001), although with high heterogeneity (I² = 83%), possibly reflecting variations in patient selection, operator expertise, and technical differences among studies. In terms of safety, no significant difference was observed in adverse event rates between UEMR and ESD (OR = 0.48, 95% CI [0.10–2.34], Z = 0.90, p = 0.37), indicating comparable safety profiles. However, UEMR demonstrated an advantage in procedural time, being 5.89 times faster than ESD (p < 0.0001). This suggests that while UEMR may offer time efficiency, it comes at the cost of lower en-bloc and R0 resection rates, raising questions about its suitability for lesions requiring complete and margin-free excision. Further studies are needed to clarify the impact of these differences on long-term patient outcomes and to determine the optimal indications for UEMR in clinical practice.

Conclusion

UEMR offers a quicker alternative to ESD but lacks its high resection quality, making ESD preferable for lesions requiring en-bloc or R0 resection. Gastroenterologists must weigh UEMR’s speed against ESD’s superior efficacy. Standardizing UEMR techniques may improve its resection quality and expand its role in clinical practice. Future research should optimize UEMR and address variability in resection outcomes.

References

1. Nett A, Binmoeller K. Underwater Endoscopic Mucosal Resection. Gastrointest Endosc Clin N Am. 2019 Oct;29(4):659-673. doi: 10.1016/j.giec.2019.05.004.
2. Ferlitsch M et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024. Endoscopy. 2024;56(1):1-20. doi: 10.1055/a-2304-3219.
3. de Souza MHG, Ribeiro IB, de Moura DTH, et al. Underwater versus conventional endoscopic mucosal resection for colorectal lesions: a systematic review and meta-analysis of randomized clinical trials. Surg Endosc. 2023;37(5):3456-3465. doi: 10.1007/s00464-022-09456-7
4. Chandan S, Mohan BP, Khan SR, et al. Safety and efficacy of underwater versus conventional endoscopic mucosal resection for colorectal polyps: Systematic review and meta-analysis of RCTs. Gastrointest Endosc. 2023;97(6):1087-1095.e3. doi: 10.1016/j.gie.2023.01.012.
5. Inoue T, Nishida T, Maekawa A, et al. Underwater endoscopic mucosal resection versus endoscopic submucosal dissection for 20–30 mm colorectal polyps: a prospective randomized study. Endoscopy. 2022;54(5):456-464. doi: 10.1055/a-1500-1234.
6. Park SS, Lee IS, Lee SH, et al. Comparison of underwater endoscopic mucosal resection and endoscopic submucosal dissection of rectal neuroendocrine tumors (with videos). Gastrointest Endosc. 2021;93(3):637-646.e2. doi: 10.1016/j.gie.2020.08.030.
7. Takeuchi Y, Uedo N, Hotta K, et al. Underwater endoscopic mucosal resection for colorectal lesions: Can it be an “Underwater” revolution? World J Gastroenterol. 2020;26(20):2545-2553. doi: 10.3748/wjg.v26.i20.2545.

Introduction

There is increasing recognition that effective resident training in gastrointestinal endoscopy should be provided by endoscopists who have received formal educational training in the teaching of endoscopy.¹ While the implementation of Training the Colonoscopy Trainers (TCT) courses has led to significant improvements in colonoscopy quality outcomes^2,3 and polyp detection rates,⁴ evidence regarding the impact of TCT participation on teaching performance and resident learning – both of which are main goals of faculty development initiatives – is still lacking. Therefore, the aim of the present study was to evaluate the effectiveness of TCT course implementation using Kirkpatrick’s model of training evaluation.

Aims & Methods

In this study, 24 gastroenterologists from a university hospital and two affiliated general teaching hospitals in the north-eastern educational region of the Netherlands, participated in a two-day TCT course. The course was evaluated at three levels of Kirkpatrick’s model: (a) post-course evaluations reflecting the initial reaction; (b) video analysis of endoscopy training in the workplace before and after the TCT course using the mini-Structured Training Trainer Assessment Report (mini-STTAR); (c) a post-course resident survey reflecting the impact on the home-environment. Descriptive statistics and non-parametric tests were used to analyse the effectiveness of the TCT course.

Results

The TCT course was well received by participants, they highlighted the use of a structured training framework as a strength. Video analysis of endoscopy training in the workplace demonstrated a significant improvement in post-course trainer performance, both at 1-3 months (T1) and 6-9 months (T2). Significant improvements were found in the overall mini-STTAR scores (p<0.001), and across most mini-STTAR items, particularly in the items related to the phase preceding the actual training (referred to as the Set) and the evaluation after completion of the training (referred to as the Closure). Regarding the actual training (referred to as the Dialogue), participants demonstrated a significant positive change in ‘guiding/deconstructing’ and ‘controlling’ (both at T1 and T2) and in ‘encouraging/praise’ (only at T2). Participants received significantly higher 5-point Likert scale ratings as ‘excellent trainer’ at T1 (mean 4.13) and T2 (mean 4.29), compared to baseline (mean 3.58, p<0.001). In the post-course survey, all residents (N=16) were satisfied with the supervision of endoscopy trainers in their teaching hospitals. Nine (56%) reported uniform endoscopy supervision among trainers, a significant increase compared to a pre-course resident survey (8%, p=0.034).⁵ Although residents reported that the frequency of a didactic Set and Closure did not increase, most respondents indicated that the implementation of the TCT course improved the setting of learning objectives, the provision of spontaneous feedback, guidance during difficult endoscopies, and the prevention of undesired scope takeover.

Conclusion

The implementation of a TCT course provided a structured and useful training framework, and enhanced trainer performance, particularly in the didactic pre- and post-endoscopy training discussions, as well as in guiding, controlling, encouraging, and providing spontaneous feedback during the training of residents in gastrointestinal endoscopy.

References

1. Antonelli G, Voiosu AM, Pawlak KM, et al. Training in basic gastrointestinal endoscopic procedures: a European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement. Endoscopy. 2024;56:131-150
2. Waschke KA, Anderson J, Macintosh D et al. Training the gastrointestinal endoscopy trainer. Best Pract Res Clin Gastroenterol. 2016;30:409-419
3. Gavin DR, Valori RM, Anderson JT, et al. The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut. 2013;62:242-249
4. Hoff G, Botteri E, Huppertz-Hauss G, et al. The effect of train-the-colonoscopy-trainer course on colonoscopy quality indicators. Endoscopy. 2021;53:1229-1234
5. Mousset RA, de Vos Tot Nederveen Cappel WH, Pierie JEN et al. Endoscopy training in the Netherlands: a national survey among gastroenterology residents. Endosc Int Open. 2022;10:E1548-E1554

Introduction

Endoscopic submucosal dissection (ESD) demands a high level of endoscopic skill and extensive training, even for experienced endoscopists, with a particularly steep learning curve for colonic ESD. Over the last three years, the French Society of Digestive Endoscopy (SFED) has implemented a structured ESD training program. This study aimed to evaluate the effectiveness of the SFED ESD training program to achieve competency in ESD and to identify factors associated with it.

Aims & Methods

Participants who attended the SFED ESD training curriculum over the past three years were invited to join the study. After completing a standardized initial simulation training week, each participant was asked to document each ESD procedures performed in their training center, along with technical details for each (lesion size and location, en bloc resection, R0 resection status, and procedural complications). Additionally, participants completed an online survey to gather information about their practice environment, ongoing ESD activity, and demographic data (e.g., gender, age, prior endoscopy experience). Successful dissection was defined as en-bloc resection with free lateral and deep margins (R0) and no need for surgical intervention due to complications. The performance threshold for achieving proficiency in ESD was defined, in line with ESGE guidelines, as achieving an en-bloc resection rate of >90% and a complication-related surgery rate of <1%. The learning curve to reach these competence standards was assessed using the LC-CUSUM method.

Results

A total of 45 students participated in the study. The majority were men (70%), with a median age of 36 years. They practice endoscopy for 6 years (IQR 4-10) and 82% performed interventional endoscopy (ERCP and EUS).
A total of 2,068 ESD procedures were performed by the trainees. The median number of ESDs conducted post-training was 34 (IQR 22-66), with the majority being colorectal (42.9% rectal and 42.7% colonic). Lesions had a median size of 45 mm (IQR 34-60), with a resection speed of 17.4 mm²/min (IQR 10.5-26.5). En bloc resection and R0 resection were achieved in 93.6% and 85.8% of cases, respectively, with a surgical complication rate of 0.94%. The overall success rate of ESD procedures was 92.7%. Success was more likely in rectal (97%) than colonic (90.4%) procedures. 75% of the students were competent. Among those who reached competence, the median number of ESDs required was 45. Factors associated with competency were : ESD localization (rectum > colon), the age (HR 0.92 [0.86-0.99]; p = 0.03) and experience (HR 0.91 [0.84-0.99]; p = 0.03) were inversely correlated to the competency. Practiced in a high volume ESD center (>100 ESD/year) lead to reach competency faster (p =0.008).

Conclusion

This study provides the first assessment of the SFED ESD training program in France. Competence in ESD is reachable after appropriate training. A big experience is not needed to attempt ESD. Supervised training is essential, and seems easier in a high-volume center to achieve competence more quickly. These findings may help inform the selection of future candidates for ESD training to ensure effective skill acquisition and safe practice.

Disclosure

nothing to disclose

Clinical Case Summary

Our patient was a 66yr Chinese man who was treated for active Chronic Hepatitis B from 2009 with Lamivudine, Adefovir and then switched to Tenofovir from 2020 with long term undetectable Hepatitis B viral load (HBV VL) and normal Liver function tests. His ultrasound liver was normal and Fibroscan 6.9kpa in 2021. Hepatitis B Surface quantification was 87 IU/ml. ALT 28.
The patient was enrolled in a research trial which randomized him to stopping Tenofovir with close follow up.
At week 4 after stopping Tenofovir, his HBV VL became detectable at 2.53log and ALT 31.
At week 8, his HBV VL increased to 5.55log and ALT 35.
At week 10, HBV VL was 6.85, ALT 384, Bilirubin and INR normal. HBeAg remained negative and the patient remained asymptomatic.
He was promptly restarted on Tenofovir but his ALT continued to rise and peaked at 832 at week 12 before gradually returning to normal as did his Hepatitis B viral load.
At week 13, he developed tingling over his hands and feet.
At week 14, he was admitted for clumsiness with reduced sensation over the feet and hands. He had no other systemic symptoms suggestive of any infections.
Examination revealed subjective reduction in sensation over the distal peripheral limbs. Power was normal but reflexes were absent over the ankles and knees.
MRI brain was normal.
Lumbar puncture showed high CSF protein 0.7gL but normal cell count. Nerve Conduction study (NCS) reported acute inflammatory demyelinating polyneuropathy.
EMG was unremarkable.
A probable diagnosis of GBS was made.
His ALT was down to 304 and HBV VL 3.82 log.
NCS repeated 2 months later and showed similar inflammatory demyelinating polyneuropathy.
NCS repeated 4 months later showed significant improvement which confirmed a diagnosis of GBS
1 year from his first presentation, he recovered fully.
Only 7 cases of Hepatitis B related GBS have been reported in the literature. Our case highlights GBS resulting from Hepatitis B flare

References

none

Introduction

While the link between oral hygiene and systemic disease has been widely studied, large-scale studies specifically examining the association between oral hygiene or periodontal disease (PD) and colorectal cancer (CRC) remain scarce.

Aims & Methods

We aimed to investigate the association between oral hygiene indicators and the risk of CRC using a nationwide, population-based dataset from the Korean National Health Insurance Service (NHIS). The first was based on the National Health Screening (NHS) database, incorporating self-reported oral hygiene behaviors and dentist-conducted clinical dental examination findings. The second analysis utilized claims data from the NHIS database, focusing on PD as the primary exposure. We identified individuals aged ≥19 years newly diagnosed with CRC between January 2012 and December 2019, and controls without any history of cancer, matched at a 1:4 ratio using extensive propensity score (PS) matching. Multivariable conditional logistic regression was performed to adjust for potential confounders, including demographics, comorbidities, lifestyle factors, and laboratory values.

Results

In the NHS-based analysis, a total of 2,188,968 individuals were analyzed. Following PS matching, the matched dataset comprised 35,668 CRC cases and 141,850 controls. Several oral health indicators were significantly associated with increased CRC risk, including objective dental findings such as decayed teeth (adjusted odds ratio [aOR], 1.08; 95% confidence interval [CI], 1.05–1.11), missing teeth (aOR, 1.14; 95% CI, 1.11–1.17), severe gingivitis (aOR, 1.21; 95% CI, 1.15–1.26), and dental calculus (aOR, 1.10; 95% CI, 1.07–1.12), as well as poor oral hygiene-related behaviors or symptoms such as infrequent dental visits (aOR, 1.04; 95% CI, 1.02–1.07), poor perceived oral health (aOR,1.06; 95% CI, 1.02-1.10),
infrequent daily toothbrushing (aOR,1.20; 95% CI, 1.14–1.24), infrequent brushing before bedtime (aOR, 1.05; 95% CI, 1.02–1.08), non-use of interdental cleaning devices (aOR, 1.10; 95% CI, 1.07–1.13), and tooth pain (aOR, 1.03; 95% CI, 1.00–1.06). In the claims-based analysis, among 5,266,776 individuals, 133,482 CRC cases and 528,559 matched controls were included after PS matching. In the multivariable analysis, PD was independently associated with an increased risk of CRC (aOR, 1.03; 95% CI, 1.01–1.04). Additionally, in subgroup analyses stratified by age, sex, alcohol consumption, smoking status, and obesity, objective dental examination findings consistently showed a significant association with increased CRC risk across all subgroups.

Conclusion

Poor oral hygiene and PD were significantly associated with an elevated risk of CRC in this large-scale, population-based study. These findings highlight the potential importance of oral health in screening and prevention of CRC.