Introduction

The indications for colonoscopy are well established, with the primary objective being the detection of neoplasia or lesions that carry a high risk for colorectal cancer, even though benign causes are more commonly encountered. In young adults under 50 years of age, common indications include rectal bleeding and diarrhea. In contrast, individuals aged 50 years and older are screened more broadly due to the increased risk of colorectal cancer, although recent trends show a rising incidence of neoplastic lesions in younger adults as well. ​

Aims & Methods

The aim of our study is to compare the indications and outcomes of colonoscopy between individuals younger and older than 50 years, and to identify which indications are most strongly associated with neoplastic findings.
A retrospective, descriptive, and analytical study was conducted over a period of 3.5 years, involving 1,518 patients. Participants were divided into two groups: Group A included patients under 50 years old, while Group B comprised those aged 50 and above. Epidemiological, clinical, and endoscopic data were compared between the two groups. Patients with a known diagnosis of inflammatory bowel disease (IBD) were excluded from the study. Statistical analysis was carried out using SPSS version 21.0.

Results

Among the patients, 65.1% were over 50 years of age, while 34.9% were under 50. The mean age in group A (under 50) was 37.5 ± 9 years, compared to 64.4 ± 9 years in group B (over 50). Females predominated in the younger group (55.3%), whereas males were more prevalent among older patients (56.3%) (p < 0.001). A personal history of colorectal cancer was more frequent in patients over 50 (10.5% vs. 4.4%; p < 0.001).
Colonoscopy indications varied by age group: constipation was the most common indication in group B (29.1% vs. 22%; p = 0.01), whereas diarrhea predominated in group A (33.3% vs. 19.3%; p < 0.001). Pathological findings on colonoscopy were more frequent in older patients (49.1% in group B vs. 32.9% in group A; p < 0.001).
In patients under 50, the most common pathological findings were colitis or ulcerative colitis (47.9% vs. 11.7%; p < 0.001). In contrast, patients over 50 showed a higher prevalence of polyps (61.5% vs. 41.3%; p < 0.001) and rectocolonic neoplasia (16% vs. 5%; p = 0.002).
Among the colonoscopy indications, constipation in patients under 50 was associated with a higher risk of neoplastic lesions (p = 0.007), while in patients over 50, rectal bleeding and constipation were significantly associated with neoplastic lesions (p < 0.001).

Conclusion

The presence of neoplastic lesions was strongly associated with constipation in individuals under 50 years of age, and with both rectal bleeding and constipation in those over 50. Further studies to better define these indications could help improve the appropriateness of colonoscopy, particularly in younger patients.

Introduction

Increased intestinal permeability, mediated by zonulin, has been implicated in the pathogenesis of insulin resistance, dyslipidemia, and non-alcoholic fatty liver disease (NAFLD). Small intestinal bacterial overgrowth (SIBO) may further contribute to metabolic dysfunction through endotoxin-induced inflammation.

Aims & Methods

The aim was to determine zonulin concentrations in patients with dyslipidemia and NAFLD and analyze their relationships with metabolic parameters and the prevalence of small intestinal bacterial overgrowth (SIBO). A total of 342 patients with dyslipidemia were enrolled; NAFLD was confirmed in 152 of them based on ultrasound and steatometry. Fecal zonulin levels were measured using ELISA; SIBO was assessed by hydrogen breath test. Lipid profiles, high-sensitivity C-reactive protein (hsCRP), and HDL-C levels were also analyzed.

Results

Zonulin levels in patients with NAFLD (115±2.76 ng/g) exceeded the normal range (≤107 ng/g), compared to 87±0.28 ng/g in the dyslipidemia group without NAFLD (p<0.05). SIBO was present in 45% of dyslipidemic patients and 53.2% of those with NAFLD. A positive correlation was found between zonulin and hsCRP (r=0.65) and triglycerides (r=0.58), and a negative correlation between SIBO and HDL-C (r=–0.78) in the dyslipidemia group.

Conclusion

Elevated zonulin and increased intestinal permeability are associated with higher cardiometabolic risk in patients with NAFLD and dyslipidemia. Both zonulin and SIBO may serve as potential therapeutic targets for preventing progression of NAFLD and related metabolic disturbances.

Introduction

Gilbert's Syndrome (GS) is a benign polymorphism of the UGT1A1 gene, leading to decreased enzyme activity in the liver and mildly increased levels of unconjugated bilirubin in blood (= hyperbilirubinemia), that is affecting 5-12% of the worldwide population. A mild hyperbilirubinemia (HBIL) is associated with reduced chronic inflammation, a lower risk for metabolic and cardiovascular disorders, and lower levels of reactive oxygen species (ROS). Despite these associations, HBIL effects on the intestine, as the primary site of bilirubin excretion, and its interactions with the gut microbiota remain unclear. We propose that chronic HBIL redirects bilirubin excretion through the intestinal epithelium that affects microbe-host interactions in the colon.

Aims & Methods

Germ-free (GF) and specific-pathogen-free (SPF) C57BL/6N wildtype (WT) mice with induced HBIL and transgenic mice with the human UGT1A1*28 polymorphism (TG) were investigated, the latter one mimicking chronic HBIL. WT mice with induced HBIL received intraperitoneal bilirubin injections for 12-14 days. Bilirubin levels, in the intestine, gut content and serum were analyzed using the fluorescent protein UnaG, which specifically binds to unconjugated bilirubin, and microbiota composition was analyzed by 16S rRNA gene sequencing. To characterize HBIL-associated antioxidative function, colonic adenoma cell lines (Ptk-6, HCT116, HT-29-MTX-E12) and small intestinal organoids were incubated with different levels of bilirubin and the generation of ROS and oxidative stress markers measured.

Results

In general, mice of the induced HBIL groups exhibited higher bilirubin levels in the colonic mucosa, indicating "intestinal HBIL" with increased concentrations of mucosal bilirubin being detected in SPF HBIL > GF HBIL mice (SPF HBIL = 12.34 nM/mg, GF HBIL = 9.9 nM/mg; SPF control = 0.5951 nM/mg; GF control = 8.21 nM/mg), as well as a lower hepatic Ugt1a1 expression. Intracellular uptake of bilirubin was confirmed when different human and murine colonic epithelial cell lines were treated with bilirubin in vitro. Intestinal HBIL led to altered gut microbiota compositions, characterized by decreased abundances of operational taxonomic units (OTUs) associated with Gram-negative taxa (e.g., Prevotellaceae) and increased levels of OTUs associated with Gram-positive taxa (e.g., Lachnospiraceae) under intestinal HBIL conditions. Gut microbiota changes were more pronounced in TG (=chronic HBIL) compared to induced HBIL mice. In vitro experiments showed decreased detection of ROS and markers of cellular oxidative stress in a HCT116 reporter cell line dependent on bilirubin presence (Nfk-⁠β, Nrf2 and Hif1α). Small intestinal organoids from TG mice showed an altered proliferation pattern in comparison to WT organoids.

Conclusion

The results suggest an altered bilirubin excretion through the intestinal epithelium under mild HBIL that alters gut microbiota composition. These effects were more pronounced under chronic HBIL conditions, suggesting a sustained effect of GS-like HBIL on the gut microbiota.

Introduction

Endoscopic submucosal dissection (ESD) for early upper gastrointestinal (GI) tumors creates large mucosal defects with risks of bleeding, perforation, and strictures, particularly in the esophagus where post-ESD stricture rates reach clinically significant levels. Current closure methods are inadequate for managing esophageal defects due to anatomical complexity. We present an endoscopy-integrated platform for real-time in situ nanofiber deposition during upper GI ESD, leveraging blow spinning technology to address these limitations.

Aims & Methods

This study aimed to
(1) engineer a coaxial nozzle system compatible with standard upper GI endoscopes (working channel ≤3.7 mm),
(2) optimize nanofiber deposition parameters for esophageal wound repair, and
(3) validate therapeutic efficacy in preclinical models.
A simplified in vitro setup was used to optimize polymer composition (polycaprolactone/gelatin blends), gas pressure (0.2-0.5 MPa), and blowing distance (10-20 cm). A murine skin wound model was employed to validate nanofiber adhesion and repair properties. For endoscopic integration, a dual-layer coaxial nozzle was designed using computational fluid dynamics (CFD), featuring an inner polymer delivery channel (0.5 mm inner diameter) and an outer airflow channel (1.2 mm inner diameter) to generate nanofibers via controlled airflow. The nozzle was fabricated using stereolithography 3D printing with biocompatible resins and integrated into a compact endoscopic system. Functional testing was performed in a transparent esophageal phantom under simulated physiological flushing, followed by in vivo validation in a porcine esophageal ESD model comparing nanofiber-treated wounds to controls.

Results

The 3D-printed coaxial nozzle (3.0-mm outer diameter) demonstrated full compatibility with standard upper GI endoscopes. In simulated esophageal conditions, the platform achieved uniform nanofiber deposition (fiber diameter: 15.2±3.6 μm) with robust adhesion unaffected by luminal flushing. In the porcine esophageal ESD model, immediate nanofiber application provided complete wound coverage, reduced perioperative bleeding, and prevented stricture formation. Histological analysis at 4 weeks revealed markedly reduced fibrosis and enhanced mucosal regeneration in treated groups compared to controls. The system operated seamlessly within the standard ESD workflow without procedural interference.

Conclusion

This study develops the first endoscopy-compatible platform for real-time in situ nanofiber deposition, demonstrating preclinical efficacy in addressing post-ESD complications in the upper gastrointestinal tract. By synergizing mechanical barrier formation with bioactive healing modulation, the technology reduces stricture risks and promotes mucosal repair in porcine esophageal ESD models. While current findings underscore its translational promise, further optimization of biomaterial formulations and rigorous human trials are essential steps toward clinical adoption in therapeutic upper GI endoscopy.

Introduction

Anorectal dysfunction affects approximately 8% of the global population.¹ Whilst conservative management can manage mild symptoms, surgery is often indicated in patients with structural abnormalities and severe symptoms. A Magnetic Resonance Imaging Defecating Proctogram (MRDP) forms a key part of patients’ pre-surgical investigations, visualising the anterior, middle and posterior compartments of the pelvis, and provides a dynamic image of the pelvic floor during defecation. It has been criticised as it is often performed in the supine position, which does not reflect normal physiological positioning for defecation.² However, little is known about how patients themselves feel about how this test reflects their usual defecatory process.

Aims & Methods

As part of a service evaluation, between September 2024 and April 2025, all patients who underwent an MRDP at Imperial College Healthcare NHS Trust in London, United Kingdom, were asked to complete a 21-item questionnaire exploring their experiences, prior to, during and after their MRDP. Five-point Likert Scales (1 - Strongly Disagree, 5 - Strongly Agree) were used for each question, except two concluding questions on overall experience, which were answered using free-text boxes. Patients with insufficient cognitive function or comprehension of English to complete the questionnaires were excluded.

Results

Thirty-eight patients responded to the questionnaire, and after excluding those with missing data, 35 completed questionnaires were included in the analyses (30[86%] female, 28[80%] 50-79 age category). Reasons for referral to MRDP included FI (15/35 [43%]) and/or constipation (13/35 [37%]) and/or POP (9/35 [26%]). Although 32(91%) strongly agreed that their privacy was respected, and none strongly agreed they felt embarrassed, just 12(34%) strongly agreed that they felt ‘comfortable during the test’. Less than a third of patients (10[29%]) agreed that they were able to ‘defecate as they do at home’ and only a quarter (9[26%]) felt that defecating lying supine was easy. Whilst 16(46%) patients felt that the contrast mixture inserted gave them a ‘normal urge to open their bowels’, only 4(12%) reported that the contrast mixture was ‘similar to their own stool’. Nevertheless, 23(66%) patients agreed that the experience matched what they would expect, and most patients (29[83%]) would have the test again if it were necessary. Patients aged 70-79 were associated with disagreeing with the statement that they could ‘defecate as they would at home’ (neutral/disagree/strongly disagree vs. agree/strong agree: 8/8[100%] vs 0.0[0%], p = 0.011).

Conclusion

Whilst patients reported being able to tolerate the MRDP, the large majority reported that defecating during the investigation did not reflect their usual defecatory process. Contrary to expectation, it appears that patients’ main complaints were not due to embarrassment, but rather patient position and environment. Whilst patient experiences are highly institution and staff dependent, understanding patients’ perspectives during an MRDP is useful for optimisation of pre-investigation counselling and expectation setting. Implementing post-MRDP questionnaires, or pro-active clinician exploration of the extent to which patients felt able to replicate their symptoms could facilitate clinical interpretation of MRDP results. Moving towards evacuation testing that aligns more closely with a patient's normal defecatory habits is likely to yield results that better reflect symptom profiles and therefore provide better insights into specific surgical targets responsible for symptom generation.

References

1. Jaafari H, Houghton LA, West RM, et al. The national prevalence of disorders of gut brain interaction in the United Kingdom in comparison to their worldwide prevalence: Results from the Rome foundation global epidemiology study. Neurogastroenterology & Motility. 2023; 35:e14574. doi:10.1111/nmo.14574
2. Pilkington, S.A., Nugent, K.P., Brenner, J., Harris, S., Clarke, A., Lamparelli, M., Thomas, C. and Tarver, D. (2012), Barium proctography vs magnetic resonance proctography for pelvic floor disorders: a comparative study. Colorectal Disease, 14: 1224-1230. https://doi.org/10.1111/j.1463-1318.2012.02945.x

Introduction

A grey zone known as the borderline resectable (BR) category, which lies between resectable and unresectable, has been proposed for perihilar cholangiocarcinoma; however, there is no international consensus on this classification. BR can be considered from various perspectives, including local tumor factors, surgical risk, long-term prognosis, liver reserve capacity, and systemic condition.

Aims & Methods

The study's aim is to define the borderline resectable (BR) of perihilar cholangiocarcinoma based on surgical procedure and preoperative liver function. We examined 1) the comparison of surgical outcomes between extended surgery and standard surgery and 2) the risk of postoperative mortality from liver failure in patients who underwent portal vein embolization.
Study 1) Surgical cases from January 2011 to December 2023 were divided into two groups: the Extended surgery group: left or right trisectionectomy(L3/R3), concomitant hepatic artery resection (AR), hepatopancreaticoduodenectomy (HPD), and the other standard surgery groups. Study 2) The risk of postoperative liver failure in patients who underwent resection after portal vein embolization (PVE) between January 2001 and December 2022 (including HPD) was evaluated

Results

Study 1) A total of 181 patients (59 in the extended surgery group and 122 in the standard surgery group) were included in the study. There were significant differences in operation time (median 798/700 minutes, p<0.01) and blood loss (2000 ml/1295 ml, p<0.01) in the extended surgery group compared to the standard surgery group, but no significant differences in postoperative complication rate (Clavien Dindo 3a or higher: 79%/67%) or in-hospital mortality rate (5%/5%). The 5-year overall survival rate was 34% in the extended surgery group and 50% in the standard surgery group, which was not significantly different by the log-rank test. Study 2: The incidence of liver failure (%) and mortality (%) by surgical technique were R (37/5.7), L3 (30/5), and R3 (54/7.7). ICGK x proportion of remnant liver volume（ICGKF）<0.05 before PVE, operation time >660 minutes, and blood loss >1900 ml were identified as risk factors in univariate and multivariate analyses, and the mortality rate for patients with these three factors was high at 25%.

Conclusion

Patients who required extended surgery with poor pre-PVE liver function (ICGKF<0.05) should be considered BR in perihilar cholangiocarcinoma.

References

1: Nooijen LE, de Boer MT, Braat AE, Dewulf M, den Dulk M, Hagendoorn J, Hoogwater FJH, Lam HD, Molenaar Q, Neumann U, Porte RJ, Swijnenburg RJ, Zonderhuis B, Kazemier G, Klümpen HJ, van Gulik T, Groot Koerkamp B, Erdmann JI.
National consensus on a new resectability classification for perihilar cholangiocarcinoma - A modified Delphi method. Eur J Surg Oncol. 2025 Feb;51(2):107117. PMID: 37880001.
2: Kuriyama N, Usui M, Gyoten K, Hayasaki A, Fujii T, Iizawa Y, Kato H, Murata Y, Tanemura A, Kishiwada M, Sakurai H, Mizuno S, Isaji S.
Neoadjuvant chemotherapy followed by curative-intent surgery for perihilar cholangiocarcinoma based on its anatomical resectability classification and lymph node status. BMC Cancer. 2020 May 11;20(1):405. doi: PMID: 32393197;.
3: Matsuyama R, Mori R, Ota Y, Homma Y, Yabusita Y, Hiratani S, Murakami T, Sawada Y, Miyake K, Shimizu Y, Kumamoto T, Endo I.
Impact of Gemcitabine Plus S1 Neoadjuvant Chemotherapy on Borderline Resectable Perihilar Cholangiocarcinoma.
Ann Surg Oncol. 2022 Apr;29(4):2393-2405. doi: 10.1245/s10434-021-11206-4. Epub
2022 Jan 7. PMID: 34994885.

Introduction

In laparoscopic cholecystectomy (LC), intraoperative cholangiography (IOC) is recommended to clarify biliary anatomy, detect choledocholithiasis and identify complications. IOC interpretation may be performed by either surgeons or radiologists, but it remains unclear which approach is preferable. This study investigates how the type of medical specialist interpreting the IOC affects surgical outcomes and operating time.

Aims & Methods

All LCs registered in the Swedish Registry of Gallstone surgery and Endoscopic retrograde Cholangiopancreatography (GallRik) between January 1, 2009, and December 31, 2020, were included. A complementary survey was distributed to all participating surgical clinics to determine local IOC interpretation practices. Registry and survey data were linked and outcomes were analysed using mixed model analysis and logistic regression.

Results

A total of 118.556 procedures from 61 surgical units were included. Operating time was longer when radiologists assessed the IOC (mean differences 11.3 minutes; 95% CI 1.60-20.89). Intraoperative complications were more common with radiologist interpretation (2.6% vs 1.5%; OR 0.58, 95% CI 0.52-0.63), while postoperative complications were slightly higher with surgeon-led interpretation (8.2% vs 7.3%; OR 1.14, 95% CI 1.08-1.20). Bile duct injury rates (0.3%; OR 1.0, 95% CI 0.79-1.27) and detection of choledocholithiasis (12.4% vs 12.6%; OR 1.02, 95% CI 0.90-0.99) were similar between groups.

Conclusion

Surgeon-led IOC interpretation is associated with shorter operating times and fewer intraoperative complications, without increasing the risk of bile duct injury or missed choledocholithiasis. Routine radiologist involvement may be unnecessary and an inefficient use of resources.