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 66-year-old presented with a one-day history of abdominal pain and fevers. Computer tomography imaging (CT) revealed a foreign body in a sigmoid colon diverticulum with perforation and collection. A sigmoidoscopy failed to identify the foreign body. Ultrasound-guided foreign body extraction was unsuccessful. Surgical treatment was deemed high risk due to comorbidities and he was treated conservatively. Twelve days following a second sigmoidoscopy was performed due to persisting collection. A fish bone was found puncturing a sigmoid diverticulum. A through-the-scope (TTS) clip and methylene blue dye were applied. Removal was achieved with a snare. An over-the-scope clip (OTSC) successfully sealed the perforation.
Endoscopy is proving to be an increasingly viable minimally-invasive option for the treatment of foreign body colonic perforations when used early and in the absence of peritonitis or clinical instability¹. Unique to this case is that endoscopic closure was performed one week following perforation with associated collection, factors considered to influence procedure success due to inflammatory change^1,2. A standard TTS clip was unlikely to achieve closure strength. We used the OTSC system, designed to achieve full-thickness closure³. The technical complexity of using the OTSC system was visualisation which requires colonoscope withdrawal and mounting of a cap reducing endoscopic visibility. TTS clip and dye application prior to OTSC application proved beneficial in achieving definitive endoscopic perforation management. This is a technical aspect that to our knowledge has not been documented elsewhere in the literature.
Lessons:
1. Endoscopy can be effective in delayed colonic perforation management avoiding the need for surgery.
2. A three-step technique is proposed: 1) application of a locator (TTS clip and dye) 2) foreign body removal 3) OTSC application of the perforation site.
Fig1 CT image of fish bone and collection
Fig2 Endoscopic image OTSC

References

1) Morais R, Marques M, Macedo G. Endoscopic treatment of a foreign body–associated colonic perforation. Int. J. Colorectal Dis. 2020; 35: 165-167.
2) Rogalski P, Daniluk J, Baniukiewicz A et al. Endoscopic management of gastrointestinal perforations, leaks and fistulas. World J Gastroenterol. 2015; 21: 10542-10552.
3) Kobara H, Mori H, Nishiyama N et al. Over‐the‐scope clip system: A review of 1517 cases over 9 years. JGH. 2019; 34:22-30.

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

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.

Introduction

Personalizing biologic therapies in inflammatory bowel disease (IBD) remains a critical unmet need. Here, we investigated circulating and stool microRNAs (miRNAs) as prognostic markers for treatment response across three biologics - anti-TNF, vedolizumab (VEDO), and ustekinumab (UST) - and explored their relationship with gut microbiome to uncover potential host-microbe predictors of response.

Aims & Methods

This study included 43 IBD patients (mean age 40.4 years, 25.6% female, 20.1% with ulcerative colitis) enrolled in the ILEITIS cohort at National University Hospital, Singapore. The majority had received anti-TNF (n=35), whilst others were given VEDO (n=9), or UST (n=15) therapies. Clinical non-response was defined as disease flare within 48 weeks post-induction, indicated by C-reactive protein >5 mg/L, fecal calprotectin >150 μg/g, or moderate to severe endoscopic inflammation. Baseline serum and stool samples were collected and isolated for miRNA profiling by the ID3EAL^TM PanoramiR microRNA Knowledge Panel (MiRXES) via the QuantStudio5-384-well qPCR system (Applied Biosystems). Fecal microbial communities were assessed via shotgun metagenomic sequencing. Differential expression analysis and Spearman correlation with false discovery rate (FDR) adjustment were performed to explore miRNA–microbe associations and treatment response patterns.

Results

Among 376 paired serum and stool miRNAs analyzed, only six exhibited significant positive correlations, indicating largely compartment-specific expression patterns. Stool miRNAs demonstrated stronger and more numerous correlations with gut microbial taxa (11 significant pairs, FDR < 0.05), whereas serum miRNAs showed no strong associations. Biologic-specific miRNA signatures were identified. Predictive modelling identified top-ranked miRNA with high discriminative performance for treatment response; serum miR-296 and stool miR-134 perfectly predicted VEDO response (AUROC = 1.0); serum miR-146 predicted UST response (AUROC = 1.0); and stool miR-302 robustly predicted anti-TNF response (AUROC = 0.897). Correlation analysis between biologic-responsive miRNA and microbial taxa revealed 12 significant correlations for stool-derived miRNA and 14 for serum-derived miRNA. Notable microbial species involved in these associations include Bacteroides uniformis, Parabacteroides distasonis, Phocaeicola dorei, Clostridium scindens, Streptococcus sanguinis, Bilophila wadsworthia, Hungatella hathewayi, and Clostridium leptum, all taxa implicated in IBD-associated dysbiosis, showed significant correlations (FDR < 0.05).

Conclusion

Stool- and serum-derived miRNAs capture non-overlapping but complementary dimensions of host response to biologic therapy in IBD. There are significant overlaps between host miRNAs and microbiome readouts suggesting plausible links between key microbial responders to therapy and host regulatory miRNAs, especially in the luminal compartment. Our findings highlight the value of integrating compartment-specific miRNA and microbiome profiling to improve precision medicine approaches in IBD.

Introduction

Early-onset inflammatory bowel disease (EO-IBD), defined as disease onset before the age of 6 years, represents a distinct subgroup of pediatric IBD. It is associated with extensive colonic involvement, resistance to standard therapy, and a higher risk of complications, including extraintestinal manifestations (EIMs).

Aims & Methods

The purpose of our study was to analyze the clinical features of EO-IBD in children of a large gastroenterological center in the Russian Federation. This retrospective single-center cohort study included 37 children diagnosed with EO-IBD between 2019 and 2024. Clinical and demographic data were collected from outpatient records. Intestinal symptoms (abdominal pain, stool frequency and consistency, pathological impurities) and EIMs were assessed. Special attention was given to the timing of EIM onset relative to intestinal symptoms.

Results

The study included 37 patients — 17 with Crohn’s disease (CD) and 20 with ulcerative colitis (UC) — all of whom were diagnosed before or at the age of 6. The median (Me) age at diagnosis was 5 years for both UC (IQR 3 – 6) and CD (IQR 4 – 6). The groups were comparable in terms of sex (p = 0.56) and age (p = 0.81). The median time from symptom onset to diagnosis was 10 months for UC (IQR 6.25 – 18) and 8.5 months for CD (IQR 5.5 – 15.8), with no significant difference between the groups (p = 0.74). Growth retardation (SDS < –2) was observed in four boys with CD at age 6. The most common symptoms in CD were abdominal pain (64.7% vs 60% in UC; OR 0.82; CI 0.22 – 3.12; p = 0.77) and weight loss (29.4% vs 7.1%; p = 0.019). Fever occurred exclusively in the CD group (35.3%). In contrast, UC was more frequently associated with diarrhea (90% vs 70.6% in CD; OR 3.75; CI 0.62 – 22.6; p = 0.13) and blood in stool (85% vs 64.7%; OR 0.32; CI 0.067 – 1.57; p = 0.15). EIMs were observed in 7 of 20 (35%) UC patients and 7 of 17 (41.2%) CD patients. The most frequent EIM in both groups was peripheral arthritis – found in 3 UC patients (10%) and 5 CD patients (29.4%) (p = 0.29). Peripheral arthritis was significantly more likely to occur after the onset of intestinal symptoms (p < 0.001). In two patients of each group, an EIM was the first manifestation of disease. In 43.2% of patients, an accurate diagnosis was not possible at disease onset, and they were initially classified as having IBD-unclassified (IBD-U). During follow-up, the time to establish a definitive diagnosis was measured. The median time to UC diagnosis was 24 weeks (IQR 20 – 48), and for CD it was 40 weeks (IQR 30–45.5) (p = 0.56).

Conclusion

EO-IBD in young children presents with specific phenotypic traits and a high rate of EIMs. Delayed diagnosis is common, particularly in cases initially classified as IBD-U. Our findings emphasize the need for early recognition and accurate differentiation of IBD subtypes in this challenging age group.

Disclosure

No financial support has been provided for this work. The authors declare that there is no conflict of interest.