Introduction

Sigmoid volvulus is usually managed by endoscopic detorsion in the absence of complications, while surgery is reserved for severe cases. However, recurrence rates remain high, ranging from 18% to 90% (1). The guidelines from the American Society of Colon and Rectal Surgeons (1) recommend prophylactic surgery, although the optimal timing is not defined. In Europe, most cases are sporadic and affect elderly patients with comorbidities. However, large studies mainly originate from endemic regions, which limits their applicability to Western settings. Moreover, there is a lack of large-scale data focusing specifically on the endoscopic management of sigmoid volvulus.

Aims & Methods

The study aimed to evaluate the outcomes of patients with sigmoid volvulus managed by endoscopic detorsion during out-of-hours emergency endoscopy shifts across multiple centers.
We conducted a retrospective, multicenter study (8 centers), including all patients who underwent endoscopy for suspected sigmoid volvulus during on-call digestive endoscopy shifts between March 2016 and December 2023. Procedures were performed by the POET group (Parisian On-call Endoscopy Team), a mobile unit composed of an endoscopist and a nurse, covering urgent endoscopy during nights and weekends in Paris and suburbs (6.9 million inhabitants), using a portable system (2).

Results

A total of 404 patients were included. Median age was 72 years (IQR 59; 83), 69% were male, 19% institutionalized, 40% had neurocognitive disorders, 26% had anatomical abnormalities of the colon and 45% had constipation. The most common presenting symptoms were abdominal pain (53%), bowel obstruction (17%), and constipation (20%). Endoscopic detorsion was successful in 92% of cases, with a 2% perforation rate and 89% of clinical success. Predictors of technical failure included ischemia at endoscopy (OR 0,16 [0,07-0,37], p<0,0001) and history of abdominal surgery (OR=0,44 [0,2;0,99], p=0,0463). Ischemia was independently associated with initial CRP ≥ 27 mg/L (OR=2,24 [1,11-4,54], p=0,0253), time to endoscopy ≥ 10h (OR=2,38 [1,28-4,39], p=0,0058), and radiological signs of severity (OR=4,13 [1,82-9,36], p=0,0007). All 24 patients with colonic necrosis at endoscopy died without emergency surgery, regardless of the success of detorsion (58% in this subgroup). In 28% of cases, endoscopy was performed for recurrence. Among patients with a first episode, recurrence occurred in 40%, with 50% occurring within 12 days. Endoscopic success was associated with a higher risk of recurrence (OR=4,39 [1,18-16,32], p=0,0271). In-hospital and 30-day mortality was <10%; overall mortality at the latest follow-up was 31% (median follow-up : 9 months, IQR 2-31).

Conclusion

Emergency endoscopic detorsion is highly effective with low morbidity. However, in the presence of colonic necrosis, endoscopic treatment is ineffective and uniformly fatal without surgical intervention. Optimal patient selection is therefore critical, and relies on early identification of predictive factors for ischemia. Volvulus recurrence is frequent and early, highlighting the need for systematic prophylactic treatment following successful detorsion. Elective surgery during the same hospitalization should be considered whenever possible. For patients with surgical contraindications, endoscopic sigmoidopexy may offer a viable alternative.

References

1. Alavi K, Poylin V, Davids JS, Patel SV, Felder S, Valente MA, Paquette IM, Feingold DL; Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction. Dis Colon Rectum. 2021 Sep 1;64(9):1046-1057. doi: 10.1097/DCR.0000000000002159. PMID: 34016826.
2. Camus M, Becq A, Jaïs B; Parisian On-Call Endoscopy Team; Dray X. Resource-sparing urgent endoscopies by a mobile on-call team in the Paris area during the COVID-19 outbreak. Gastrointest Endosc. 2020 Aug;92(2):447-448. doi: 10.1016/j.gie.2020.04.021. Epub 2020 Apr 16. PMID: 32305344; PMCID: PMC7161514.

Introduction

The achievement of histological remission (HR) is a key treatment goal in ulcerative colitis (UC), as it is suggestive of better disease management and predicts response to therapy.
The absence of neutrophils in epithelium and lamina is crucial to define HR. However, the role of neutrophil number and localisation remains unclear. We aimed to develop a novel artificial intelligence (AI)-driven system to automate neutrophil detection, localisation, and quantification, supporting assessment of HR and enable the prediction of response to therapy.

Aims & Methods

We developed an AI-driven system by integrating two deep learning models to (1) segment whole slide images (WSIs) into epithelium, crypts and lamina propria and to (2) detect and quantify neutrophils. Outputs from these models were combined to compute neutrophil densities in the lamina propria, epithelium, and overall tissue. The optimal neutrophil density cut-offs to assess disease activity (Geboes score >2B.0) in UC patients were identified in the AMAC phase 2 Mirikizumab trial, and subsequently validated in the multicentre prospective PICaSSO cohort study. Cut-offs to determine treatment response at weeks 12 and 52 (histological improvement [HI; Geboes score ≤3.1] and histological remission [HR; Geboes score ≤2B.0]), were also evaluated.

Results

Table 1 shows the system diagnostic performance in assessing disease activity and predicting response to therapy at W12 and W52 in the Mirikizumab cohort.
303 WSIs from active UC patients from the multicentre, randomised, double-blind, parallel-arm, placebo-controlled phase 2 clinical trial of Mirikizumab were analysed. The model yielded a DICE SØrensen of 0.57 for segmentation, precision of 82.3% and recall of 77.0% for neutrophil detection. The system identified an overall optimal neutrophil density cut-off (cells/mm²) predictive of disease activity of >21.7.0 (>10.1 and >30.4 for epithelium and lamina propria, respectively), with an accuracy of 86% (85% and 85%, respectively). Further validation in the multicenter PICaSSO cohort yielded to similar results.
Moreover, the overall optimal cut-off to predict histological remission at W52 was <20.8 (<10.4 and <27.9 for epithelium and lamina propria, respectively), with an accuracy of 82.0% (81% and 80%, respectively).

Conclusion

Our novel AI-based system demonstrates strong potential as an automated tool to detect, localise, and quantify neutrophils to assess histological activity and predict response to therapy in a clinical trial UC cohort and real-world settings. This framework could be applied in clinical trials and routine clinical practice, offering objective guidance for personalised management in UC patients.

References

[1] Santacroce G, Meseguer P, Zammarchi I, et al. P406 A novel active learning-based digital pathology protocol annotation for histologic assessment in Ulcerative Colitis using PICaSSO Histologic Remission Index (PHRI). Journal of Crohn's and Colitis, Volume 18, Issue Supplement_1, January 2024, Pages i843–i844
[2] Graham S, Vu QD, Jahanifar M, et al. CoNIC Challenge: Pushing the frontiers of nuclear detection, segmentation, classification and counting. Med Image Anal. 2024;92:103047.

Disclosure

MI received research grants and consultant fees from Olympus, Pentax, Eli Lilly, and Janssen. All other authors declare no competing interests.