Introduction

Colonoscopy is a standard procedure but it is unclear whether a short or long colonoscope is more favorable regarding procedure efficiency and patient comfort. The performance of different colonoscope lengths cannot be objectively compared in live patients due to various limitations. Hence, the choice of colonoscope length is a matter of personal preference or institutional tradition. Preclinical tools to assess scope performance are needed. We evaluated endoscopists’ performance using short vs. long colonoscopes in the Mikoto simulator, enabling objective measurements using pressure and distension sensors within a 3D-printed, calibrated colon model.

Aims & Methods

Aims: i) Performance comparison of short vs. long comparison in the Mikoto simulator, enabling objective measurements using pressure and distension sensors within a 3D-printed, calibrated colon model. ii) First evaluation of this novel simulator.
Delegates at ESGE Days and DGE-BV 2024 were invited to perform two simulation rounds—one with each scope length in a random order —and completed a survey. Main outcome was the performance of different scope lengths as measured by the caecal intubation time and the proprietary “Mikoto score” (a combination of pressure and distension measurements exerted on the model).

Results

Of 281 participants, 252 complete datasets were analyzed (187 ESGE, 65 DGE-BV). The Mikoto-Score was lower with long scopes (74 vs. 77; p=0.01), and caecal intubation time was longer (2:59 vs. 2:38 min; p=0.01). A second round did not improve performance. Mikoto-Scores were unaffected by scope preference or sedation strategy but were lower in users of the two-person technique. Scores correlated with self-assessed skill and colonoscopy experience (r=0.43, r=0.47). The median system-usability score was 77.5 indicating a good evaluation by the examiners and a good usability.

Conclusion

Using the Mikoto simulator, long colonoscopes caused more colonic distension and longer insertion times, potentially impacting patient comfort. Objective simulator data can inform scope selection in clinical practice. The Mikoto simulator reflects endoscopist self-assessed skill and previous experience.

Disclosure

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. doi:10.1055/a-2205-2613
2. Lee SH, Lee DJ. Comparison on colonoscopic parameters according to length of adult-colonoscope. Chin Med J (Engl) 2014; 127: 85-91.
3. Obstein KL, Patil VD, Jayender J et al. Evaluation of colonoscopy technical skill levels by use of an objective kinematic-based system. Gastrointest Endosc 2011; 73: 315-321, 321.e311. doi:10.1016/j.gie.2010.09.005
4. Repici A, Badalamenti M, Maselli R et al. Efficacy of Real-Time Computer-Aided Detection of Colorectal Neoplasia in a Randomized Trial. Gastroenterology 2020; 159: 512-520 e517. doi:10.1053/j.gastro.2020.04.062
5. de Groen PC. Advanced systems to assess colonoscopy. Gastrointest Endosc Clin N Am 2010; 20: 699-716. doi:10.1016/j.giec.2010.07.012
6. Fennerty MB, Earnest DL, Hudson PB et al. Physiologic changes during colonoscopy. Gastrointestinal endoscopy 1990; 36: 22-25.
7. Ofori E, Ramai D, John F et al. Occupation-associated health hazards for the gastroenterologist/endoscopist. Ann Gastroenterol 2018; 31: 448-455. doi:10.20524/aog.2018.0265
8. Williams C, Teague R. Colonoscopy. Gut 1973; 14: 990-1003. doi:10.1136/gut.14.12.990
9. Barthel J, Hinojosa T, Shah N. Colonoscope length and procedure efficiency. J Clin Gastroenterol 1995; 21: 30-32. doi:10.1097/00004836-199507000-00008
10. Kim K-M, Lee S-H, Lee D-J et al. A Randomized Controlled Trial of Comparison on Time and Rate of Cecal and Termianl Ileal Intubation according to Adult-Colonoscope Length: Intermediate versus Long. J Korean Med Sci 2014; 29: 98-105.
11. Sakai Y. Technique of colonoscopy. Gastroenterologic endoscopy 1987; 2: 1253-1280.
12. Lee HL, Eun CS, Lee OY et al. Significance of colonoscope length in cecal insertion time. Gastrointestinal Endoscopy 2009; 69: 503-508. doi:https://doi.org/10.1016/j.gie.2008.06.006
13. Kim YG, Kim KJ, Yang DH et al. Intermediate-length colonoscope needs more training duration than long-length colonoscope. Scand J Gastroenterol 2014; 49: 1007-1013. doi:10.3109/00365521.2013.856465
14. Dubow RA, Katon RM, Benner KG et al. Short (35-cm) versus long (60-cm) flexible sigmoidoscopy: a comparison of findings and tolerance in asymptomatic patients screened for colorectal neoplasia. Gastrointest Endosc 1985; 31: 305-308. doi:10.1016/s0016-5107(85)72211-0
15. Stoffel EM, Murphy CC. Epidemiology and Mechanisms of the Increasing Incidence of Colon and Rectal Cancers in Young Adults. Gastroenterology 2020; 158: 341-353. doi:10.1053/j.gastro.2019.07.055
16. Fujii M, Onoyama T, Ikebuchi Y et al. A novel humanoid-robot simulator for colonoscopy. Endoscopy 2020; 53: E291-E292. doi:10.1055/a-1264-6804
17. Ward ST, Mohammed MA, Walt R et al. An analysis of the learning curve to achieve competency at colonoscopy using the JETS database. Gut 2014; 63: 1746. doi:10.1136/gutjnl-2013-305973
18. Siau K, Pelitari S, Green S et al. JAG consensus statements for training and certification in colonoscopy. Frontline Gastroenterol 2023; 14: 201-221. doi:10.1136/flgastro-2022-102260
19. Bundesärztekammer. (Muster-)logbuch-13.4-FA Innere Medizin und Gastroenterologie. In: Bundesärztekammer; 2011:
20. Haycock A, Koch AD, Familiari P et al. Training and transfer of colonoscopy skills: a multinational, randomized, blinded, controlled trial of simulator versus bedside training. Gastrointestinal Endoscopy 2010; 71: 298-307. doi:10.1016/j.gie.2009.07.017
21. Vajpeyi A, Naidu AS, Hawel JD et al. A multi-modal training environment for colonoscopy with pressure feedback. Surgical Endoscopy 2024. doi:10.1007/s00464-024-11442-1
22. Gomez PP, Willis RE, Van Sickle K. Evaluation of two flexible colonoscopy simulators and transfer of skills into clinical practice. J Surg Educ 2015; 72: 220-227. doi:10.1016/j.jsurg.2014.08.010
23. Mu Y, Yang X, Guo F et al. Colonoscopy Training on Virtual-Reality Simulators or Physical Model Simulators: A Randomized Controlled Trial. Journal of Surgical Education 2024; 81: 1339-1345. doi:https://doi.org/10.1016/j.jsurg.2024.07.020
24. Shumaker DA, Zaman A, Katon RM. A randomized controlled trial in a training institution comparing a pediatric variable stiffness colonoscope, a pediatric colonoscope, and an adult colonoscope. Gastrointestinal Endoscopy 2002; 55: 172-179. doi:https://doi.org/10.1067/mge.2002.121189
25. Tribonias G, Bacasis AD, Komeda Y ​

Introduction

Inflammatory bowel diseases (IBD), including Crohn’s disease and ulcerative colitis, are chronic conditions with alternating phases of flare-ups and remission. Due to the persistent and often severe course of these diseases, effective treatment significantly improves patients' daily activities and overall functioning. [1] Given the uncertain prognosis and the frequent disease progression despite pharmacotherapy, it is important to explore additional interventions that could support traditional treatments. While physical activity may provide both anti-inflammatory and functional benefits in IBD, data on its efficacy and safety during disease exacerbation remain scarce. [2] This pilot study is the first real-world investigation into the effects of a supervised physical exercise training in patients hospitalized due to IBD flare.

Aims & Methods

This study aimed to evaluate the effects of an individualized, moderate-intensity, supervised physical exercise training on exercise tolerance, inflammation, and fatigue resistance in patients hospitalized due to IBD flare, and to explore baseline factors associated with greater benefit from the intervention. Patients were randomly assigned to an intervention group, receiving individual cycloergometer training during hospitalization, or to a control group without exercise. Both groups were well balanced at baseline, with no significant differences in demographic, clinical, or laboratory parameters. At both admission and discharge, all patients underwent standardized graded exercise tests to establish their exercise tolerance based on the lactate threshold and heart rate/power output response. Furthermore laboratory assessments, and the Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F) questionnaire were conducted.

Results

A total of 22 patients were included in the study, with 13 patients in the intervention group and 9 patients in the control group. Although FACIT-F scores improved in both groups, the intervention group demonstrated a significantly greater improvement (median change –39 points; IQR –49 to –11; p = 0.014) compared to the control group (median change –25 points; IQR –52 to –6; p = 0.30). Baseline FACIT-F scores were significantly correlated with changes in heart rate response response during exercise: patients with greater baseline fatigue and poorer functional status experienced greater improvement in exercise tolerance (r = –0.62, p = 0.028). Platelet counts remained more stable in the intervention group (median change +10 ×10³/µl; IQR –65 to +45) compared to a significant increase in the control group (median +74 ×10³/µl; IQR +44.5 to +101.75; p = 0.046). In the intervention group, greater reductions in calprotectin were strongly correlated with more favorable heart rate responses during a graded exercise test (r = –0.92, p = 0.009).

Conclusion

Supervised training program during hospitalization for IBD flare was associated with improved fatigue resistance and more favorable inflammatory responses. Patients with worse baseline functioning obtained greater benefit in exercise tolerance. These findings support the feasibility and potential therapeutic role of individualized physical activity in acute IBD care and highlight the need for further investigation in real-world settings.

References

1. Farrell D, Artom M, Czuber-Dochan W, Jelsness-Jørgensen LP, Norton C, Savage E. Interventions for fatigue in inflammatory bowel disease. Cochrane Database Syst Rev. 2020 Apr 16;4(4):CD012005. doi: 10.1002/14651858.CD012005.pub2.
2. Achtenberg M, Cibor D, Zwolińska-Wcisło M. Structured exercise in patients with inflammatory bowel disease: a literature review. Gastroenterology Review/Przegląd Gastroenterologiczny. 2025;20(1):36-40. doi:10.5114/pg.2025.148473.

Disclosure

Magdalena Achtenberg has received lecture fees and/or travel grants from Ferring and Eli Lilly, unrelated to the present work. Tomasz Dziubyna has received travel grants from Fresenius, unrelated to the present work. Małgorzata Zwolińska-Wcisło, Dorota Cibor, Karolina Gazda, Magdalena Wyrzykowska, Piotr Kosieniak, Maria Wiśniewska, Jerzy A. Żołądź, Marcin Grandys and Joanna Majerczak declare no conflict of interest.

Introduction

Neurosurgical patients often face several difficulties with nutritional support due to severe brain injury, neurological disease, or post-surgical complications. This study aimed to assess the outcomes of long-term enteral nutrition via percutaneous endoscopic gastrostomy (PEG) in this population.

Aims & Methods

Single center, retrospective analysis of patients who were referred for PEG from 2001 to 2023. Patients who presented with severe traumatic brain injury (TBI), hemorrhagic stroke, brain tumor or other conditions that required neurosurgery were selected. Demographic, anthropometric and clinical data were recorded.

Results

196 patients were included, 57% were younger than 65 years. Stroke (41.8%), TBI (35.2%) and brain tumors (19.9%) were the most frequent conditions. The median time from diagnosis to PEG was 94 days. At the time of PEG procedure, only 38.5% were underweight. 21 patients were lost to follow up. Among the remaining, 75.4% died, 12.6% were alive and PEG-fed, and 12% had the tube removed. Of the surviving patients who remained PEG-fed, the majority (77%) were stroke patients. Median overall survival post-PEG was 11.5 months, with 88% of patients surviving more than one month. Albumin, transferrin, and total cholesterol levels at the time of PEG were associated with longer survival. Albumin (p<0.001) and transferrin (p<0.01) were significantly associated with lower short-term mortality risk.

Conclusion

PEG is an effective method for long-term enteral nutrition in neurosurgical patients. Although survival is limited, reflecting the severity of the underlying conditions, the majority of patients survived beyond one month, supporting the adequacy of the procedure. Higher serum albumin levels were associated with longer survival, suggesting its potential role as a prognostic biomarker in this population. Careful patient selection, timely intervention, and consideration of nutritional status may help optimize outcomes for neurosurgical patients requiring PEG.

Introduction

Primary biliary cholangitis (PBC) is a chronic autoimmune liver disease characterized by progressive bile duct damage and cholestasis. While ursodeoxycholic acid (UDCA) is the first-line therapy, about 40% of patients have incomplete responses, necessitating alternative treatments.

Aims & Methods

This meta-analysis evaluates the efficacy and safety of novel oral anti-cholestatic agents for PBC, focusing on key biochemical and symptomatic outcomes. A systematic literature search was conducted across electronic databases. Eligible studies included randomized controlled, retrospective, and open-label trials investigating novel oral anti-cholestatic agents in PBC patients. Data on efficacy (e.g., alkaline phosphatase [ALP] reduction) and safety outcomes were extracted and analyzed using meta-analytic techniques.

Results

Ten studies involving 878 patients were analyzed. Investigated therapies included seladelpar, fenofibrate, saroglitazar, bezafibrate, elafibranor, and budesonide. Novel anti-cholestatic agents significantly lowered ALP levels compared to controls (SMD -2.80; 95% CI [-3.56, -2.03]; p<0.00001), with saroglitazar showing the largest effect size (SMD -4.62; 95% CI [-5.54, -3.70]). Subgroup analysis revealed that fibrates (fenofibrate, bezafibrate, and saroglitazar) demonstrated the most consistent ALP reduction across studies (SMD -3.15; 95% CI [-3.89, -2.41]; p<0.00001).
In addition to ALP reduction, several agents showed improvements in other liver function tests. Bilirubin levels decreased significantly with novel therapies (MD -0.22 mg/dL; 95% CI [-0.35, -0.09]; p=0.001). Gamma-glutamyl transferase (GGT) also showed substantial reduction (SMD -1.98; 95% CI [-2.56, -1.40]; p<0.00001).
Symptomatic improvements were observed, particularly for pruritus. Bezafibrate and seladelpar demonstrated the most promising results, with mean reductions in visual analog scale scores for pruritus of 30% and 35%, respectively. Fatigue scores also improved, though to a lesser extent (SMD -0.42; 95% CI [-0.68, -0.16]; p=0.002).
Safety profiles were comparable to controls, with no significant increase in serious adverse events (OR 1.21; 95% CI [0.81, 1.83]; p=0.35). The most common adverse events were mild gastrointestinal symptoms (10-15% of patients) and transient elevations in creatinine (5-8% of patients). No significant hepatotoxicity was observed across the studies.

Conclusion

Novel oral anti-cholestatic agents show promise in managing PBC patients with suboptimal UDCA responses, demonstrating significant improvements in biochemical markers and some symptomatic relief. However, study heterogeneity, small sample sizes, and limited follow-up durations restrict direct comparisons and generalizability. Further research is needed to confirm long-term efficacy and safety.

References

1 Trivella J, John BV, Levy C. Primary biliary cholangitis: Epidemiology, prognosis, and treatment. Hepatol Commun 2023; 7: e0179. [PMID: 37267215 DOI: 10.1097/HC9.0000000000000179]
2 Purohit T, Cappell MS. Primary biliary cirrhosis: Pathophysiology, clinical presentation and therapy. World J Hepatol 2015; 7: 926-941. [PMID: 25954476 DOI: 10.4254/wjh.v7.i7.926]
3 Tanaka A, Takikawa H, Mochida S, Koike K, Miwa H, Shimosegawa T. Changing nomenclature for PBC from ‘primary biliary cirrhosis’ to ‘primary biliary cholangitis’. J Gastroenterol 2016; 51: 748-749. [PMID: 27230619 DOI: 10.1007/s00535-016-1223-z]

Introduction

Type 1 gastric neuroendocrine tumors (T1-gNETs) are well-differentiated, typically indolent neoplasms associated with chronic atrophic gastritis (CAG) and hypergastrinemia, with nearly 100% long-term survival. However, they have a high recurrence rate of 30-60% within the first year after resection. Tumor size is the most critical prognostic factor, while the role of grading is less definitive compared to other digestive NETs. International guidelines recommend conservative management for tumors <1 cm, advocating for approaches such as endoscopic resection or surveillance, which have shown excellent outcomes. However, the management strategies and outcomes for tumors > 1 cm remain less clearly defined due to the lack of scientific data in this specific patient population.

Aims & Methods

This study aimed to investigate management strategies and clinical outcomes in a homogeneous population of patients with T1-gNETs > 1 cm. The findings are expected to provide valuable insights and guide the development of more effective management strategies.
The present study was designed as an international multicentric retrospective analysis, conducted in 7 Western centers. It included consecutive patients diagnosed with T1-gNETs >1 cm in diameter, collected between 2004 and 2023, with at least 12 months of follow-up. The primary endpoints were disease progression (DP) (tumor recurrence or metastasis development) and the Progression-Free Survival. The Cox regression method was used to identify factors associated with progression.

Results

The study included 104 patients (61 females, 43 males) with a median age of 61 years and a median tumor size of 15 mm (range 11–60 mm). 61.5% of tumors were classified as G1, 37.5% as G2, and 1% as G3. 75 patients (72.1 %) underwent endoscopic resection (27 EMR, 5 m-EMR, 14 ESD, 7 snare polypectomy, and 22 unspecified techniques). Surgical procedures were performed in 33 patients (31.7%), 13 of whom had previously undergone endoscopic resection. One patient (1%) received treatment with somatostatin analogues, while 8 patients (7.7%) received no treatment.
The R0 resection rate was 51.9%. During follow-up, 26 patients (25%) experienced recurrence, 7 (6.7%) developed metastases, and 12 (11.5%) died, with 2 deaths (1.9%) due to tumor-related causes. The median overall survival and progression-free survival were 59.5 months (range 13–215) and 51.5 months (range 4–215), respectively.
Univariate analysis showed that R0 resection (HR 0.32, p=0.02) and advanced endoscopic techniques (m-EMR/ESD) (HR 0.09, p=0.02) were associated with better outcomes. In contrast, other resection methods (standard EMR, snare polypectomy, or unspecified techniques) and tumor size were associated with a higher risk of disease progression (HR 10.13, p=0.02; HR 1.03, p=0.003, respectively).

Conclusion

T1-gNETs >1 cm often recur and can progress, exhibiting potentially aggressive behavior, especially in larger lesions. Endoscopic resection should employ advanced techniques to prevent incomplete removal, which is associated with poor outcomes.

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