Introduction

Colonoscopy is an invasive procedure that may cause patients pain and discomfort. Moderate to deep sedation is mostly used to allow the quality of the procedure and patients comfort. However, sedation is associated with some risks and side effects. Virtual reality (VR) offers immersive and three-dimensional experiences that distract attention and patients pain. This prospective study aims to define rate of complete colonoscopies with sedation and VR to determine if the two methods are equivalent.

Aims & Methods

140 adults patients who underwent a ambulatory colonoscopy were included between April 2021 and December 2022 at University Hospital of Nancy : 70 patients under sedation and 70 others with VR. Patients and gastroenterologist completed questionnaires. The main outcome was cecal intubation. Secondary outcomes were patient pain, anxiety and comfort, patient et gastroenterologist satisfaction, total time of procedure and resection of polyps if detected.

Results

The rate of cecal intubation was 95.7% for the sedation group and 88.6% for the VR group. There was no confounding factor. The univariate analysis did not allow to conclude to an equivalence between the two methods on the success rate at the threshold of 5% (p=0.685).
There was no statistically significative difference on pain (p=0.518) and anxiety (p=0.247) before the colonoscopy.
However, statistically significant difference was observed on peri-procedural pain between sedation group (0.9/10 on the numeric scale) and VR group (3.3/10) (p=0.0006) and on the state trait anxiety inventory (STAI) rising to 40.4/80 for sedation group and 42.4/80 for VR group (p=0.003).
Patient and gastroenterologist satisfaction (respectively p=0.441 and 0.629), patient comfort (p=0.215), total time of procedure (p=0.391) and resection of polyps (p=0.888) were equivalent.

Conclusion

Our study doesn’t allow to conclude in a equivalence in the cecal intubation rate between VR and sedation.
Nevertheless, VR represents an interesting alternative for performing colonoscopy, eliminating risks associated with sedation while maintaining comfort and acceptable level of pain and anxiety for the majority of patients. Total time of procedure and polyps resection rate are not affected by the use of VR

Clinical Case Summary

Introduction: We present the case of a 30-year-old patient with severe Crohn's disease (Montreal classification A2, L3, B3). The patient had been on infliximab therapy since March 2022 with partial clinical benefit and residual endoscopic and histologic disease activity (SES-CD 6, January 2023).
Case report: In October 2023 on physical examination, the patient showed the appearance of an erythematous and painful nodule at the level of the middle third of the posterior surface of the leg. After one week, the lesion appeared ulcerated, with a necrotic base and a violaceous, raised peripheral rim.(figure 1) After dermatologic evaluation, the diagnosis of pyoderma gangrenosum was posed. This was the pustular subtype, the variant of pyoderma most related to inflammatory bowel disease. The patient started corticosteroid therapy by oral somministration and IFX therapy was discontinued. At follow-up after twenty days from the start of therapy, the patient showed a slight reduction of the lesion in question, however, in the days to follow a similar lesion appeared at the level of the left gluteal region.(figure 2) Therefore, in consultation with the dermatology specialist, it was planned to tapering corticosteroid therapy until it was completely discontinued and to start the patient on off-label treatment with Upadacitinib at dosage of 45 mg in daily single administration for twelve weeks. At week 12, both lesions showed a marked improvement.(figure 3) In addition, the patient reported clinical benefit about bowel activity. Therefore, it was decided to continue Upadacitinib with a dosage of 30 mg 1 cp/day. At week 20 of therapy, lesion resolution and healing were noted.(figure 4)
Conclusions: Our cases support the efficacy of Upadacitinib for the treatment of complicated Crohn's disease with the presence of extraintestinal manifestations. and up to our knowledge this is the first report of a successful treatment with Upadacitinib in a patient with concomitant PG and CD.

References

Figure 1: lesion ulcerated,at the level of the middle third of the posterior surface of the leg , with a necrotic base and a violaceous, raised peripheral rim.
Figure 2: lesion at the level of the left gluteal region.
Figure 3: At week 12, both lesions showed important degree of improvement
Figure 4: lesion resolution

Introduction

The introduction of lumen-apposing metal stents (LAMSs) has revolutionized the field of therapeutic endoscopic ultrasound (EUS). In the last decade, its utilization for off-label indications has markedly increased, particularly among patients with surgically altered anatomy to establish access in the excluded segment of the gastrointestinal tract. Indications for anastomosis creation include EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE), EUS-directed transgastric intervention (EDGI), or endoscopic reversal of Roux-en-Y gastric bypass (RYGB) for specific indications (see below).

Aims & Methods

This study aims to evaluate the effectiveness and safety of LAMS in patients with surgically altered anatomy for EDGE, EDGI, and reversal of RYGB. We collected data on all LAMS procedures conducted in patients with surgically altered anatomy, between October 2019 and February 2024 at the University Hospital of Ghent.
We used our prospective LAMS database and retrieved missing data from retrospective analysis of the medical patient records. The main outcome data of interest were technical success, clinical success, and adverse events. Technical success was defined as a successful placement of LAMS in the desired position. Clinical success was defined as either successful endoscopic access to the intended excluded gastrointestinal segment or achievement of the intended therapeutic goal when RYGB reversal was necessary. Adverse events were classified according to the AGREE criteria.

Results

A total of 73 LAMS procedures were performed: 70 cases of EUS-guided gastro-gastrostomy in patients with RYGB and 3 cases of EUS-guided gastro-enterostomy in patients with hepaticojejunostomy. Indications for LAMS procedures included 55 (75.3%) cases of EDGE, 13 (17.8%) cases of EDGI (such as gastroduodenoscopy and EUS), and 5 (6.8%) cases of RYGB reversal. Reversal of RYGB was required for one cachectic patient due to metastatic cholangiocarcinoma, three patients with hyperinsulinemic hypoglycemia, and one patient with therapy-resistant small intestinal bacterial overgrowth (SIBO).
The overall technical and clinical success rates were very high at 97.3% and 95.9%, respectively. Adverse events were observed in 11 out of 73 (15.1%) cases, including 7 (9.6%) minor events (AGREE score < 3) and 4 (5.5%) major events (AGREE score ≥ 3). Major events included stent migration (N=1), persistent fistula (N=2), and respiratory desaturation (N=1). All events could be successfully managed, and there were no procedure-related deaths. In 69.9% of cases, our method involved a dual-step approach, strategically implemented to await fistula maturation and reduce the risk of perforation. The median LAMS dwell time was 38 days (range 7, 431). LAMS was removed in 72.6% of the cases. Loss of LAMS patency occurred in 1 out of 73 (1.4%) cases and was endoscopically managed.

Conclusion

In conclusion, our study demonstrates that EUS-GG and EUS-GE offer an effective and safe approach to create anastomoses between gastrointestinal (GI) segments when performed by experts. With high technical (97.3%) and clinical (95.9%) success rates, LAMS proves beneficial for accessing excluded GI segments and reversing RYGB. Adverse events (15.1%) were mostly minor and manageable, with no procedure-related mortality. The extended patency duration and low re-intervention rate highlight LAMS as a minimally invasive and durable option in therapeutic endoscopic ultrasound procedures. Further prospective studies are required.

Introduction

Cancer is the second leading cause of death globally. Colon cancer is the fifth most prevalent type of cancer. Screening, particularly colonoscopy, reduces incidence by 40% and mortality by 50%. The process of bowel preparation before a colonoscopy is complex and requires the patient’s compliance. Enhanced education using a smartphone application has been shown to improve bowel preparation quality. However, heterogeneity was observed among the studies.

Aims & Methods

AIMS: To determine if providing instructions through an application enhances bowel preparation quality in Thai patients undergoing elective colonoscopy.

METHODS: From July 2022 to January 2024, a prospective, endoscopist-blinded, randomized, controlled trial was conducted. Consecutive patients aged > 18 years old who had convenient access to the Line application were randomly assigned in a 1:1 ratio to be educated via the smartphone application (APP group) or the standard education (control group). All patients received the same purgative regimen. The primary outcome was the Boston Bowel Preparation Scales (BBPS). Secondary outcomes included adenoma detection and cecal intubation rates, cecal intubation time, withdrawal time, and patient satisfaction.

Results

The trial aims to recruit 488 patients. A total of 272 patients (APP group, n = 131; control group, n =141) were preliminary analyzed. The mean age was 61.5 years old, and 29% were male. The mean BBPS was comparable between the APP and control groups (8.30 ± 0.99 vs 8.51 ± 1.19, P = 0.173). Both groups achieved adequate bowel preparation (BBPS>6) in 99.2% of cases. All secondary outcomes corresponded with the primary outcome. In the subgroup analysis among the elderly, levels of education, income, and waiting times for colonoscopies, BBPS was not impacted by the providing methods. No adverse events related to education were observed.

Conclusion

Both standard and enhanced education using the smartphone application resulted in excellent bowel preparation. Eligible patients included in this study might influence this outcome. However, using the smartphone application was well-received and could potentially replace standard education for bowel preparation.

References

1. Virani S, Bilheem S, Chansaard W, Chitapanarux I, Daoprasert K, Khuanchana S, et al. National and Subnational Population-Based Incidence of Cancer in Thailand: Assessing Cancers with the Highest Burdens. Cancers. 2017;9(8):108.

2. May FP, Shaukat A. State of the Science on Quality Indicators for Colonoscopy and How to Achieve Them. Official journal of the American College of Gastroenterology | ACG. 2020;115(8):1183-90.

3. Desai M, Nutalapati V, Bansal A, Buckles D, Bonino J, Olyaee M, et al. Use of smartphone applications to improve quality of bowel preparation for colonoscopy: a systematic review and meta-analysis. Endosc Int Open. 2019;7(2):E216-E24.

Introduction

Colonoscopy is the ‘gold standard’ investigation for assessment of the large bowel allowing diagnosis, biopsies, and therapy to be undertaken. Colonoscopy detects and prevents colorectal cancer through detection and removal of polyps, and is important in the diagnosis and treatment of non-neoplastic conditions. Poor quality colonoscopy is associated with increased rates of interval cancers. High quality colonoscopy cannot occur without good quality bowel preparation. Evidence in the UK show that 22% of failed colonoscopies were due to poor bowel preparation. Apart from the bowel cleansing agent, dietary restriction prior to colonoscopy has been shown to enhance quality of bowel preparation at colonoscopy.

Aims & Methods

We aimed to assess the information received and followed by patients in terms of dietary modification prior to colonoscopy.
A single centre prospective analysis of 60 consecutive patients attending colonoscopy at Chase Farm Hospital in London was undertaken in May 2022. Patients were asked to complete a questionnaire with information gathered about: type of bowel prep undertaken, whether written information about how to take bowel prep was received, whether a telephone consultation explaining dietary restriction prior to procedure happened, whether they followed a low fibre diet and the amount of fluid drunk.

Results

57 patients returned the questionnaire.
Of the 57 patients, 39% patients received written information on dietary restriction. A further 35% of patients received telephone information, 26% of patients receiving both written and verbal information. 56.9% of patients followed the 3 day dietary restriction. The quality of bowel preparation was inadequate (fair and poor by Aronchick scale) in 60% of those who did not follow the low fibre diet compared to 24% when followed. Patients who had seen a clinician in clinic and patients undergoing surveillance procedure were more likely to follow dietary restriction compare to direct access patients.

Conclusion

In this prospective study of clinical practice, we conclude that advice regarding dietary fibre restriction prior to colonoscopy is variable. In clinical practice, there is low compliance of dietary restriction prior to colonoscopy. We find that those who followed a low fibre diet are 40 % more likely to have a favourable bowel preparation compared to those following a high fibre diet. Those that had inadequate bowel prep required a repeat colonoscopy adding to the burden of the already stretched service. We recommend improvements in the implementation of the low residue diet in addition to the guidance of cleansing agents prior to colonoscopy.

Clinical Case Summary

Acute severe ulcerative colitis (ASUC) is a medical emergency with significant morbidity and mortality. Current guidelines recommend infliximab or cyclosporin salvage therapy for corticosteroid-refractory ASUC. Other available medical therapies, albeit effective in other settings, are still not validated in ASUC.

We report the case of a 20-year-old male with left-sided ulcerative colitis (UC), previously treated with mesalamine, who had been started on oral prednisolone for a disease flare. Due to lack of response, the patient visited the emergency department two weeks later with worsening symptoms, presenting with 10 bloody stools/day, faecal urgency, tenesmus, and weight loss. Physical examination was significant for tachycardia and diffuse abdominal tenderness. Blood tests revealed anaemia (haemoglobin 7.3 g/dL), thrombocytosis, and CRP of 31 mg/L. Stool examination was negative for C. difficile. Sigmoidoscopy showed continuous erythema, friability, erosions, and scattered ulcers. Mucosal biopsy PCR was positive for cytomegalovirus. The patient was admitted and started on intravenous corticoids and ganciclovir. On the 3rd day, failure of initial therapy was evident and an infusion of infliximab 10 mg/kg was given, producing a partial and transient response. Surgical consultation agreed to maintaining medical treatment. The decision was made to try a second dose of infliximab, again with partial and even shorter response. No anti-infliximab antibodies were detected. A third off-label infusion yielded no response whatsoever. Since the patient preferred to avoid surgery, a trial of upadacitinib 45mg/day was proposed. Complete response was achieved within 24 hours, with 3 soft non-bloody stools/day. On 1-month follow-up, the patient maintains clinical remission.

As in this case, there have been other reports of the efficacy of upadacitinib in ASUC. Upon further validation, this drug might become an invaluable addition to current treatment algorithms.

References

1. Nakase H. Acute Severe Ulcerative Colitis: Optimal Strategies for Drug Therapy. Gut and Liver. 2023 Jan 15;17(1):49–57.

2. Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019 Dec;68(Suppl 3):s1–106.

3. Gilmore R, Tan WL, Fernandes R, An YK, Begun J. Upadacitinib Salvage Therapy for Infliximab-Experienced Patients with Acute Severe Ulcerative Colitis. Journal of Crohn’s and Colitis. 2023 Dec 30;17(12):2033–6.

4. Ali NM, Shehab MA. Upadacitinib as a Rescue Therapy in Acute Severe Ulcerative Colitis: A Case Report and Review of the Literature. Am J Case Rep [Internet]. 2023 Sep 26 [cited 2024 Mar 18];24. Available from: https://www.amjcaserep.com/abstract/index/idArt/940966

Introduction

Colonoscopy is the gold standard for accurate exploration of the colon. Thus, it must be performed as efficiently as possible with the respect of pre-established quality standards to ensure optimal exploration. The patient's tolerance considerably affects the quality of sedation-free examinations and exposes to a high rate of interruption. Pharmacological sedation can solve this issue, however it can expose to significant adverse events and is not always available.

Aims & Methods

The aim of this study was to evaluate the impact of intraprocedural immersive virtual reality (VR) combining visual and auditory distraction in the improvement of the tolerance and the progress during unsedated colonoscopy. We conducted a prospective controlled study from February to April 2023 including outpatients presenting to the endoscopy unit for unsedated colonoscopy after consent. Patients were randomized into two groups: Group 1: colonoscopy with virtual reality headset. Group 2: control group without intervention.The material used was a virtual reality headset provided with a fully adjustable headband. The video content displayed on the hardware is made of several clips showing nature scenes. The audio content was adapted to allow optimal communication with the patient. We have excluded patients with severe visual and/or auditory impairment, dementia, cognitive impairment and epilepsy. All participants initially completed a form covering health issues and a validated anxiety questionnaire (STAI). After colonoscopy, all patients completed a form with questionnaires assessing per-procedural patient comfort (Gloucester), anxiety (STAI) and pain (EVS). In addition, patients in the intervention group completed a satisfaction questionnaire (NPS: net promoter score) assessing their experiences with the VR headset.

Results

In total, 63 patients were included in the final analysis: intervention group G1 (n=33) and control group G2 (n=30). The mean age was of 57 years. No patient encountered a technical problem with the equipment used and no adverse events occurred during the immersive experience. The two groups were comparable in terms of age, gender, comorbidities, body mass index (BMI) and colonic preparation assessed by the Boston score. A slightly lower time to caecal intubation was noted in the intervention group without significant difference (G1: 19 min vs G2: 26 min, p=0.07). Patients with VR mask expressed lower levels of post-procedural anxiety than those in the control group (Mean STAI G1: 47 vs G2: 53, p<0.01) and a significant decrease in the STAI score compared to pre-endoscopy values (8 points vs 4 points, p<0.01). The per-procedural pain assessed by EVS was significantly lower in the patients using VR (Mean G1: 0.44 vs G2 :1,32, p<0.01). Moreover, endoscopic examination was found to be more comfortable with virtual reality based on the Gloucester scale p <0.01. No patient reported any impediment to communication with medical staff due to the VR mask. Four patients were not satisfied with the resolution of the videos and 8 patients have expressed their preference to choose the content themselves. Patients of the intervention group were greatly satisfied with the VR experience with a mean NPS at 30.

Conclusion

Immersive VR technology is a promising, non-invasive and well-accepted simple tool for improving tolerance by reducing colonoscopy induced pain and anxiety allowing an optimized examination. It can be a useful alternative to conventional sedation if undesired or contraindicated or in health care institutions with a lack of adequate anesthesia facilities.