Introduction

There is accumulating evidence of similar oncological outcomes for patients treated by endoscopic resection or major surgery for T1 colorectal cancers. As ER is routinely offered to patients with large non pedunculated colorectal polyps (LNPCP), differentiating adenomas with high grade dysplasia (HGD) or submucosal invasive (SMI) is crucial. Crystal violet (CV) staining and magnifying endoscopy to delineate Kudo type V pit patterns may be useful for distinguishing such lesions but is almost never used in western practice. We aimed to determine the diagnostic efficacy of magnifying endoscopy with CV staining compared to indigo carmine in diagnosing HGD/SMI in patients with LNPCP.

Aims & Methods

Patients referred with LNPCP deemed suitable for ER but without confirmed invasive cancer from 01/01/2018 to 01/08/2024 were included. Patients with biopsy proven adenocarcinoma prior to referral were excluded. Patients were divided into a CV staining cohort after the introduction of this technique between September 2021 and August 2024 and compared to a cohort of patients referred between January 2018 and August 2021 when lesions were assessed with indigo carmine alone. Lesions were stained with crystal violet 0.05% or indigo carmine 0.2% and then examined in detail with magnifying endoscopy at 80-100x magnification. Sensitivity and specificity of CV staining and indigo carmine with magnifying endoscopy in diagnosing HGD or SMI on subsequent biopsy or examination of a resected specimen were calculated.

Results

1081 lesions were referred for consideration of ER and assessed with magnifying endoscopy, 594 in the crystal violet staining cohort and 487 in the indigo carmine alone cohort. Patients in both cohorts were similar in terms of age (68 years vs 70yrs), mean lesion size (44mm versus 46mm, p=0.16), sex (52% female versus 48%, p=0.17), lesion location, and incidence of submucosal invasive cancer (25% versus 22%, p=0.43). Using indigo carmine, identifying any type Vi pit had a sensitivity and specificity in diagnosing SMI/HGD of 16% and 97% (PPV 73%, NPV 67%). Using crystal violet, sensitivity and specificity of type Vi high grade (Vi HG) in diagnosing SMI/HGD was 8% and 98% (PPV 70%, NPV 64%) or any Vi pit was 16% and 92% (PPV 54%, NPV 64%). Sensitivity and specificity of type Vn pit pattern in diagnosing SMI using indigo carmine was 48% and 99% (PPV 95%, NPV 87%) and using crystal violet was 55% and 100% (PPV 99%, NPV 87%). Sensitivity and specificity of JNET 2b in diagnosing SMI/HGD was 20% and 91% (PPV 55%, NPV 66%) and JNET 3 to diagnose SMI was 55% and 100% (PPV 97%, NPV 88%). Overall, any Type V pit had a sensitivity of 71% and specificity of 92% in diagnosing SMI.

Conclusion

This study did not demonstrate a significant diagnostic benefit with the addition of crystal violet staining in diagnosing HGD/SMI in LNPCP. Assessment of vascular pattern may be as useful but equally limited. As a result of the size, complex morphology and heterogeneous histopathological nature of these lesions, small areas of invasive cancer or high grade changes relative to the lesion size are unlikely to be consistently reflected in the surface characteristics. Overall, Type V pit pattern is useful for diagnosing HGD/SMI which can guide patient counselling, but in its absence morphology and the risk of covert SMI should drive decision making regarding resection technique.

Introduction

Ingestible sensors hold the promise to revolutionize the monitoring of gastrointestinal diseases, including inflammatory bowel disease (IBD). These miniature electronic capsules could provide a minimally-invasive, cost-effective, and patient-friendly alternative to traditional endoscopic procedures, with the promise of greatly enhancing disease tracking and management.

Aims & Methods

To enable real-time, minimally-invasive monitoring of gut health, we developed the Gastrointestinal Smart Module (GISMO), a highly miniaturized ingestible sensor (3 times smaller than video capsules) that measures redox balance, pH, and temperature throughout the GI tract.
Redox balance plays a key role in regulating the intestinal barrier and mediating interactions among the host, immune system, and gut microbiota. In conditions like IBD, gastrointestinal cancers, and irritable bowel syndrome (IBS), disruptions in immune response and shifts in the gut microbiome can destabilize the balance of oxidants and antioxidants^1,2. This imbalance leads to oxidative stress, detectable through altered redox signals.
After validation in both lab and pre-clinical models, the GISMO system was tested in healthy participants.

Results

In this first-in-human trial, 66 sensors were administered to 15 healthy participants. The GISMO system demonstrated feasibility, safety, and ease of use. Participants reported ease in swallowing the sensors and expressed willingness to ingest multiple capsules. No device-related adverse events occurred throughout the study. GISMO is the first device capable of measuring in vivo redox balance, providing high-resolution data every 20 seconds. The data revealed consistent profiles from an oxidative environment in the stomach to a strongly reducing environment in the colon. This group of self-reported healthy volunteers exhibited low inter- and intra-subject variability, providing a reliable baseline for future comparative studies in patient populations.

Conclusion

This trial marks the first in vivo measurement of redox balance along the human gut, paving the way for new insights into the role of redox balance in maintaining gut homeostasis, inflammation, and the gut microbiome. The ability to conduct frequent and simple monitoring could revolutionize the way gastrointestinal diseases are tracked and managed.

References

1. Campbell, E. L. & Colgan, S. P. Control and dysregulation of redox signalling in the gastrointestinal tract. Nat Rev Gastroenterol Hepatol 16, 106–120 (2019).
2. Bourgonje, A. R. et al. Oxidative Stress and Redox-Modulating Therapeutics in Inflammatory Bowel Disease. Trends Mol Med 26, 1034–1046 (2020).

Disclosure

AE, FL, NVH, RA have filed a patent application on sensing in the gastrointestinal tract with the European (EP4197437A1) and U.S. (US20230190178A1) patent office. FL, AE, and RS have filed a patent application on measuring and localizing inflammation in the gut (application no. EP 24217111.4) with the European patent office. TTo, IDCM, AE, FL have filed a patent application on localization of an ingestible device (application no. EP24222150.5).

Introduction

A large proportion of Inflammatory Bowel Disease (IBD) patients also develop liver diseases, predominantly primary sclerosing cholangitis (PSC), and more than 80% of PSC patients also have IBD. Coexistence of both diseases in patients, increase of five times the risk of developing a colorectal cancer, and causes liver transplantation failure. Both of IBD and PSC have no curative treatment yet, and the impact of IBD on liver homeostasis and reciprocally the impact of PSC on intestinal barrier (IB) remain largely unknown.

Aims & Methods

The aims of the study were to investigate the impact of (1) mouse models of IBD on liver homeostasis and (2) the impact of mouse models of PSC on IB integrity. Two models of colitis have been used. A model was conducted by adding 3% DSS in drinking water for five days, followed by two days of regular water. The second model of colitis was performed using a pre-sensitizing step involving subcutaneous injection of 2% oxazolone and five day later, a rectal injection of 1.5% oxazolone. As PSC mouse models, we used intra-peritoneal injection of 1µL/g mice weight of CCl₄ twice a week for 8 weeks and another model with a 0.1% diethyl 1,4-dihydro-2,4,6-trimethyl-3,5-pyridinedicarboxylate within diet for 3 weeks. Colitis and cholangitis severities were monitored by food consumption, macroscopic observations as well as calculation of Disease Activity Index which sum up scores of weight loss, bleeding and stool consistency. Fecal samples were tested for calprotectin and lipocalin by ELISA to estimate gut inflammation. Intestinal permeability (IP) was investigated in vivo by estimation of FITC-Dextran quantity in mice’s sera after oral administration and at mice sacrifice in ileum and colon tissues by measuring the flux of fluorescein sodium salt in Ussing chamber. To study liver homeostasis, we performed pathological analysis (H&E and Sirius red staining), and real-time PCR with a focus on fibrosis markers, bile acids metabolism and metabolic pathways.

Results

IBD models induced strong alteration of colonic homeostasis including increased fecal markers of inflammation (Calprotectin and Lipocalin-2) and tissues mRNA expression of inflammatory cytokines (Ifng…). These models of colitis were also accompanied by elevated IP and impaired liver genes expression level of fibrosis (Col3a1) and fatty acids metabolism (Fasn…), as well as cholesterol and bile acids transporters (Abcb11…). This was found to be correlated with impaired enterohepatic circulation of bile acids in the gut. Furthermore, an increase expression of mRNA markers of inflammation (Cxcl1…) was only observed in the liver of the DSS colitis model. However, no alteration of liver homeostasis, including infiltrated immune cells or fibrosis was revealed by histological analysis. PSC mouse models induced strong alterations of liver homeostasis and were associated with altered gut homeostasis shown by a strong increased IP.

Conclusion

Our data demonstrate that IBD colitis models impair liver homeostasis, while PSC models disrupt intestinal integrity. The data obtained from both IBD and PSC models demonstrated a significant increase in intestinal permeability, thereby underscoring it’s potential as an association between those diseases. Further investigations are ongoing in ours models as a next step will be to study a combination of both protocols to explore disease progression and severity.

References

Rabiee, Anahita, and Marina G Silveira. “Primary sclerosing cholangitis.” Translational gastroenterology and hepatology vol. 6 29. 5 Apr. 2021, doi:10.21037/tgh-20-266
Kim, You Sun et al. “Primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD): a condition exemplifying the crosstalk of the gut-liver axis.” Experimental & molecular medicine vol. 55,7 (2023): 1380-1387. doi:10.1038/s12276-023-01042-9

Introduction

Gastrointestinal (GI) endoscopy requires not only technical skills but also strong non-technical abilities like communication, teamwork, and decision-making. Traditional training is often individualized, with little focus on interdisciplinary collaboration. Role Swapping (RS) — where physicians and nurses exchange tasks during simulated procedures — may enhance teamwork and mutual understanding.

Aims & Methods

A prospective pilot study was conducted involving 22 participants (10 endoscopists, 12 nurses) using in-silico colonoscopy simulators. The training included a pre-simulation skills assessment, theoretical onsite classes, randomized role-swapping simulation sessions, and a post-simulation evaluation after two weeks. Technical skills, non-technical skills (assessed via NOTSS and SPLINTS frameworks), and satisfaction were evaluated using validated questionnaires. Wilcoxon tests compared pre- and post-training scores.

Results

RS in simulated GI endoscopy training significantly enhanced both technical and non-technical competencies among participants. Post-training assessments using validated tools showed improvements across all evaluated domains. Situational awareness, decision-making, communication, teamwork, and leadership skills all exhibited statistically significant gains. Participants improved their ability to gather information (p=0.02), understand data (p=0.008), and anticipate future scenarios (p=0.002). Decision-making skills were notably enhanced, with better option consideration (p<0.001), more transparent communication of decisions (p=0.001), and greater adaptability to dynamic conditions (p<0.001). Communication improvements included more effective information exchange (p=0.007), better shared understanding (p=0.035), and increased team coordination (p=0.001). Leadership skills were also significantly strengthened, particularly in setting standards (p=0.002) and supporting teammates (p=0.012). Regarding technical skills, endoscopists reported substantial confidence improvements in tasks traditionally performed by nurses. Significant progress was observed in preparing endoscopic equipment (p=0.016), medication dilution (p=0.016), patient discharge procedures (p=0.014), instrument arrangement during interventional colonoscopies (p=0.026), and setup of patient monitoring systems (p=0.041). Confidence also increased in tasks initially rated as low-confidence, such as proper waste disposal after GI procedures (p=0.01). Nurses, conversely, enhanced their technical capabilities related to GI endoscopy performance. They showed greater proficiency in advancing the colonoscope (p=0.004), reducing loops (p=0.007), navigating angled turns (p=0.007), executing ancillary maneuvers (p=0.038), and conducting thorough mucosal inspections during withdrawal (p=0.036). Improvements were also seen in colonoscope insertion (p=0.026), understanding of colonoscopy quality indicators (p=0.011), and lesion identification (p=0.046). Participant feedback revealed high satisfaction with the RS training experience. Participants appreciated the opportunity to engage in cross-disciplinary tasks, reporting that the simulation increased their mutual respect, role awareness, and confidence in collaborative practices.

Conclusion

Role swapping during simulated GI endoscopy training enhanced both technical and non-technical skills and fostered better collaboration between nurses and physicians. This innovative educational approach shows potential to improve clinical practice quality and patient safety.

References

1. Hedges AR, Johnson HJ, Kobulinsky LR, et al. Effects of Cross-Training on Medical Teams’ Teamwork and Collaboration: Use of Simulation. Pharmacy (Basel) 2019; 7: 13.
2. de Laurentis C, Pirillo D, Di Cristofori A, et al. Boosting teamwork between scrub nurses and neurosurgeons: exploring the value of a role-played hands-on, cadaver-free simulation and systematic review of the literature. Front Surg 2024; 11: 1386887.

Introduction

Superior Mesenteric Artery Syndrome (SMAS), also known as Wilkie’s syndrome, is a rare gastrointestinal condition characterized by compression of the distal duodenum between the abdominal aorta (AA) and the superior mesenteric artery (SMA). Evidence on Wilkie’s syndrome is limited, reviews are based on small cohorts and case studies^1-3. Patients with SMAS typically present with postprandial epigastric discomfort, nausea, vomiting, stomach distention, and reflux, leading to malnutrition and weight loss. As mesenteric fat decreases due to the weight loss, the duodenal obstruction worsens, increasing SMAS symptoms. SMAS mostly affects young females aged 20-30 years and is challenging to diagnose due its overlap with dyspepsia, anorexia nervosa and median arcuate ligament syndrome^1-3. SMAS can present acutely, after weight loss from bariatric surgery, malnutrition or (hyper)metabolic disorders. It also presents chronically, due to an anatomically high duodenal position or a low aortic SMA origin^1-3. Diagnostic imaging, including computed tomography (CT) typically reveals a reduced SMA-AA angle <25° and a characteristic vertical, abrupt duodenal obstruction on barium X-ray series^1,2. Conservative treatment focuses on improving gastrointestinal motility and increasing the SMA-AA angle by weight gain to regain mesenteric fat¹. If conservative treatment fails, surgical intervention is considered, with duodenojejunostomy being most commonly performed. Yet, this carries potential severe complications such as anastomotic leakage and non-physiological gastro-duodenal changes. Recent evidence suggests laparoscopic Treitz ligament release may offer a viable and low-risk alternative^3,4.

Aims & Methods

This study aims to introduce a standardized, low risk treatment protocol for SMAS. The protocol includes: 1) Jejunal tube feeding for six-eight weeks, 2) Laparoscopic release of the Treitz ligament, and 3) SMA reimplantation⁵. The protocol was implemented at three hospitals in the Netherlands, Medisch Spectrum Twente, Franciscus, and Erasmus MC.

Results

A total of 12 patients were treated according to this protocol from 2020 until 2024. The cohort consisted of 7 (58.3%) female patients, with a mean age of 29.2 years (SD 11.8). The average weight and body mass index were 60.33 kg (SD 6.5) and 20.01 (SD 3.4). The mean SMA-AA angle measured on CT scans was 22.55° (SD 13.1). All patients started treatment with jejunal feeding. Nine patients underwent laparoscopic Treitz ligament release, with 7 experiencing complete resolution of symptoms. One patient with co-existing Nutcracker syndrome received primary SMA infra-renal reimplantation, with complete symptom release after the surgery. In two patients, symptoms persisted following Treitz ligament release, resembling gastroparesis and irritable bowel syndrome. The 2 remaining patients are planned for laparoscopic Treitz ligament release.

Conclusion

The combination of jejunal feeding followed by laparoscopic Treitz ligament release, represents a safe and effective treatment approach for SMAS; 7/9 patients who underwent the Treitz ligament release experienced resolution of all symptoms, demonstrating the efficacy of protocol. This approach offers an alternative to traditional surgical procedures, such as duodenojejunostomy, and reduces the risks of substantial short- and long-term complications. Further research with larger sample sizes is required to confirm the long-term outcomes and advantages of this protocol compared to other treatment strategies for SMAS.

References

1. Oka A, Awoniyi M, Hasegawa N, Yoshida Y, Tobita H, Ishimura N, Ishihara S. Superior mesenteric artery syndrome: Diagnosis and management. World J Clin Cases. 2023 May 26;11(15):3369-3384. doi: 10.12998/wjcc.v11.i15.3369. PMID: 37383896;
2. Navandhar PS, Shinde RK, Gharde P, Nagtode T, Badwaik N. Understanding Superior Mesenteric Artery Syndrome: Etiology, Symptoms, Diagnosis, and Management. Cureus. 2024 Jun 2;16(6):e61532. doi: 10.7759/cureus.61532. PMID: 38957238; PMCID: PMC11218894
3. Beita AKV, Whayne TF. The Superior Mesenteric Artery: From Syndrome in the Young to Vascular Atherosclerosis in the Old. Cardiovasc Hematol Agents Med Chem. 2019;17(2):74-81. doi: 10.2174/1871525717666190920100518. PMID: 31538906.
4. Fang JF, Wei B, Zheng ZH, Lei PR, Chen TF, Wei HB. Laparoscopic lysis of the ligament of treitz for superior mesenteric artery syndrome. Dig Surg. 2014;31(4-5):291-6. doi: 10.1159/000367670. Epub 2014 Oct 17. PMID: 25342434.
5. Ali T, Tomka J, Bakirli I, Bakirov I. Surgical Treatment of Wilkie's Syndrome by Vascular Transposition. Cureus. 2022 Apr 18;14(4):e24251. doi: 10.7759/cureus.24251. PMID: 35475250; PMCID: PMC9018456.
6. Pourhassan S, Grotemeyer D, Fürst G, Rudolph J, Sandmann W. Infrarenal transposition of the superior mesenteric artery: a new approach in the surgical therapy for Wilkie syndrome. J Vasc Surg. 2008 Jan;47(1):201-4. doi: 10.1016/j.jvs.2007.07.037. Epub 2007 Oct 18. PMID: 17949939