Introduction

During endoscopic submucosal dissection (ESD) of colorectal neoplasms, an interesting feature is occasionally detected in which the muscle layer under the tumour seems to be pulled upwards into the lesion in a triangle-shape. This feature is named muscle retracting sign (MR sign) and appears to indicate a potentially difficult ESD with high risk of incomplete and non-curative resection, although data about this subject is still scarce, without current studies in western countries. The aim of this study was to evaluate whether or not MR sign is associated with worst outcomes.

Aims & Methods

A retrospective analysis, using a prospectively collected database from 2 western centres, including all patients who underwent ESD for colorectal neoplasms with positivity for MR sign from July 2017 to January 2023 was performed. The presence of MR sign was determined by the endoscopist during the procedure. The results were evaluated in terms of complete, en bloc, R0 and curative resection rates, complications and local recurrence.

Results

In a total of 411 lesions treated by ESD, 26 presented MR sign (6.3%, mean size 62,3mm, range 20-180mm): 9 colonic and 17 rectal, corresponding to 26 patients (male 61.5%, mean age 70 years): 9 in colon and 17 in rectum. Morphologically and according to Paris classification, 13 were 0-Is (50%), 10 LST-G-M (38.5%), 1 0-Isp, 1 LST-G-N and 1 LST-NG-F. Technical success was achieved in 24 lesions (24/26, 92.3%) with 2 procedures aborted due to the perception of high perforation risk, both located in the colon (2/9, 22%). In the rectum, there was the need to perform intramuscular dissection in 3 procedures to complete the resection (3/17, 17.6%). Among resected lesions, en bloc and R0 resection rates were 100% and 66.7% (16/24). According to ESGE 2022 criteria, resection was considered curative in 66.7% (16/24), non-curative with high risk in 8.3% (2/24) and with local-risk recurrence in 25% (6/24). Intraprocedure complications were recorded in 2 resections (8%), both in the rectum and both perforations endoscopically managed. No recurrence was recorded in a mean follow-up time of 7 months (range 1-22 months).

Conclusion

This analysis show that MR sign is mostly present in large bulky protruding lesions and seems associated with a higher incomplete resection procedure rate in colon lesions but in rectum. Also, it seems associated with higher complication rate, namely perforations, and non-curative resection rates among resected lesions. Therefore, in the colon, an anticipated switch for surgery in clinically fit patients should be considered in the presence of this sign or even before initiating ESD when lesion morphology suggests its presence. To the authors’ best knowledge, this is the first study of the impact of the present of MRS in ESD in the West.

References

Toyonaga T, Tanaka S, Man-I M, East J, Ono W, Nishino E, et al. Clinical significance of the muscle-retracting sign during colorectal endoscopic submucosal dissection. Endosc Int Open. 2015;3(03):E246–51.
Suzuki N, Dhillon A, Seward E, Humphries A. CLIP MUSCLE PROTECTION (CLIMP) METHOD IN MUSCLE-RETRACTING SIGN DURING COLONIC ENDOSCOPIC SUBMUCOSAL DISSECTION. Gut. 2021;70(Suppl 1):A1–A262.

Disclosure

Toyonaga T, Tanaka S, Man-I M, East J, Ono W, Nishino E, et al. Clinical significance of the muscle-retracting sign during colorectal endoscopic submucosal dissection. Endosc Int Open. 2015;3(03):E246–51.

Introduction

Intestinal ultrasound (IUS) is an increasingly valuable, non-invasive imaging tool for assessing inflammatory bowel diseases (IBD). IUS training remains a significant challenge due to the need for hands-on experience and expert supervision. Traditional training programs offer limited hands-on training, restricting the competency level of trainees. To address this gap, we developed the IUS MindsView system, an innovative tele-ultrasound and augmented reality (AR) platform designed to provide real-time remote supervision and extend hands-on IUS training.

Aims & Methods

This study aimed to evaluate the feasibility and effectiveness of the system in improving trainee competency. The IUS MindsView system integrates AR glasses, real-time ultrasound streaming, and remote annotation capabilities to facilitate interactive, long-distance training. The system was deployed in two hospitals, where one trainee at each site performed IUS examinations under remote expert guidance. Over five supervised training sessions, each lasting up to two hours, trainees scanned 3-4 patients per session. The remote expert provided live feedback on probe positioning and ultrasound image interpretation through the MindsView ARNet platform, ensuring accurate imaging and anatomical identification.

Results

Both trainees completed the full 10-hour training program and reported high satisfaction with the system. They particularly appreciated the real-time expert annotations, the interactive nature of the training, and improved precision in probe handling. By the end of the study, both trainees demonstrated significant improvement in identifying bowel wall thickness, vascularity, and other key IUS parameters. They also expressed confidence in applying their newly acquired skills independently in clinical practice.

Conclusion

The system presents a scalable and accessible solution to address current limitations in IUS education, potentially reducing the need for prolonged on-site training at specialized centers. Additionally, its potential applications in telemedicine could enhance IBD patient care, particularly in remote or resource-limited settings.

Disclosure

AbbVie sponsored the project; contributed to the ideation, characterization, adaptation and the design; in writing, reviewing, and approval of the final version. No honoraria or payments were made for authorship.
Prof. Dan Carter has served as a consultant to AbbVie and has received research funding and speaker fees from AbbVie.
Dr. Tamar Thurm has received consulting and speaker fees from AbbVie.
Dr. Bernardo Melamud has received consulting and speaker fees from AbbVie.
Gabriel Dan has no conflict of interest.
Dr. Assaf Halperin and Dr. Shiran Naftelberg Blonder are employees of AbbVie and may own AbbVie stock.

Introduction

In patients with chronic pancreatitis (CP), pancreatic exocrine insufficiency (PEI) and poor nutritional intake may cause nutritional deficiencies. Guidelines advise monitoring key nutrients and supplementing is case of deficiency to prevent malnutrition-related complications. However, adherence remains low, possibly due to limited evidence on the clinical relevance of single nutrient deficiencies and the benefit of targeted supplementation. The aim of this study is to evaluate the prevalence of nutritional deficiencies in patients with CP and to identify predictors of those at highest risk. Secondary, we seek to explore association between nutritional deficiencies and malnutrition-related complications, and to provide insight into the natural course of nutritional deficiencies.

Aims & Methods

We analyzed data from the COMBO-trial, a nationwide stepped-wedged cluster randomized trial to evaluate the effect of an evidence-based algorithm for the management of CP. Measurements of fat-soluble vitamins, minerals, and albumin conducted in the outpatient clinic during the 35-month study period were included. PEI was defined as fecal elastase-1 concentration <200 µg/g or the use of pancreatic enzyme replacement therapy (PERT). The Pancreatic Exocrine Insufficiency Questionnaire (PEI-Q), designed to evaluate the severity of PEI symptoms, was administered at four distinct time points throughout the study. Supplement use was collected from health records and patient questionnaires. Multivariate logistic regression analysis was performed for the presence of multiple deficiencies. Potential predictors included patient and disease characteristics at baseline and the mean score of the PEI-Q during follow-up.

Results

In total 409 patients were included in this study. At baseline 327 (80.0%) had PEI and PERT was used by 297 (72.6%). Nutritional deficiencies were present in 195 patients (47.7%) of which 81 (19.8%) had multiple deficiencies. The prevalence of deficiencies included vitamin A in 13/172 (7.6%) patients, vitamin D 111/289 (38.4%), vitamin E 15/168 (8.9%), vitamin K 52/88 (59.1%), iron 44/137 (32.1%) calcium 4/198 (2.0%), magnesium 24/132 (18.2%) zinc 13/67 (19.4%), selenium 4/42 (9.5%), and albumin in 41/288 (14.2%) patients. No abnormal coagulation was observed in the 20 patients with vitamin K deficiency and available INR measurements. Osteopenia was diagnosed in 110/236 (46.6%) and osteoporosis in 56/236 (23.7%). Deficiencies in vitamin K and vitamin D, micronutrients critical to bone metabolism, were not associated with osteopenia or osteoporosis. Of 44 patients with an iron deficiency, 22 (50%) were anemic. Deficiency resolved without single nutrient supplementation in 71.4% (vitamin A), 75.0% (vitamin D), 50.0% (vitamin E) , 33.3% (vitamin K), 63.6% (iron), 100% (magnesium), 80.0% (zinc) of cases. Independent predictors for multiple deficiencies were more severe PEI symptoms (OR 1.86, 1.09 – 3.17) and daily alcohol consumption (OR 2.80, 1.27 – 6.18).

Conclusion

Nutritional deficiencies are present in approximately half of the patients with CP. Most nutritional deficiencies resolve without single nutrient supplementation. Predictors for multiple nutritional deficiencies were severity of PEI symptoms and daily alcohol consumption. Therefore, nutritional deficiencies should be considered a marker of malnutrition, with treatment focused on addressing the underlying cause rather than isolated correction through single nutrient supplementation.

Introduction

Acute pancreatitis (AP) is associated with an intense catabolic, local-regional and systemic inflammatory state, which can lead to changes in body composition, with prognostic implications.

Aims & Methods

Aims: To evaluate the body composition by anthropometry, bioelectrical impedance analysis (BIA) and computed tomography (CT) and its influence in AP severity, endocrine insufficiency (EnPI-AP), pancreatic exocrine (EPI-AP) and post-pancreatic enzyme replacement therapy (PERT).
Methods: Prospective longitudinal study of consecutive adult patients diagnosed with first AP episode. EPI-AP patients were randomized to receive PERT (4000IU/meal+20000IU/snack) vs. placebo (clinicaltrials.gov:NCT05480241). Body composition was assessed using anthropometry, BIA (InBody 570) and CT (cross-sectional areas L1/L3). Obesity was diagnosed for body mass index (BMI)≥30Kg/m², waist-to-hip ratio (WHR)>0.9(men)/0.85(women) and percentage total fat mass (TFM)>20%(men)/28%(women). Visceral obesity was defined by abdominal circumference (AC)>94(men)/80(women)cm, visceral fat area (VFA)≥100cm² and visceral/subcutaneous fat ratio (VSFR)≥0.4. Sarcopenia was diagnosed by skeletal muscle mass (SMM)<20(men)/15(women)Kg, SMM index (SMMi)<7.0/5.5Kg/m² and skeletal muscle area index (SMAi)<41(men)/38.5(women)cm². The three methods were correlated using spearman test and Bland-Altman plots.

Results

A total of 105 patients (65.7%(n=69) males; mean age:63.8±17.1yo) were enrolled and followed-up. AP was moderately-severe/severe in 32.4%/16.2%. EPI-AP and EnPI-AP occurred in 47.6%(n=50) and 17.1%(n=18). EPI-AP was persistent (≥6months after AP diagnosis) in 58%. After 6-month post-randomization, 44%(n=11/25) under PERT and 40%(n=10/25) under placebo resolved EPI-AP (p=0.598).
Obesity was diagnosed in 19.0%(n=20) by BMI, 97.1%(n=102)/72.4%(n=76) by WHR in antropometry/BIA, and 57.1%(n=60) by TFM. Visceral obesity was diagnosed in 78.1%(n=82) by AC, in 41.9%(n=44)/ 97.2%(n=103) by VFM in BIA/CT and in 90.5%(n=95) by VSFR. Sarcopenia was diagnosed in 1.0%(n=1) by MMS.
Considering outcomes, moderately-severe/severe AP was strongly associated with WHR by BIA (OR=10.2; p=0.034) and VFA by BIA (OR=1.08; p=0.029) and CT (OR=1.003; p=0.038). EPI-AP was statically associated with WHR by BIA (OR=11.6; p=0.048) and SMMi by BIA (OR=77.4; p=0.048) and TFM (OR=2.3; p=0.048). Severe EPI-AP was strongly associated with VSFR (OR=20;95%CI; p=0.048) and SMMi by BIA (OR=23.2; p=0.003) and CT (OR=2.3; p=0.041). SMMi by BIA (OR=14.1; p=0.030) and CT (OR=1.6; p=0.031) predicted EnPI-AP.
For obesity, TFM by BIA had a strong correlation with BMI (r=0.61; p<0.001) and a weak correlation with WHR by anthropometry (r=0.37; p<0.001). Regarding visceral obesity, VFA by BIA was weakly correlated with WHR by anthropometry (r=0.29; p=0.004) and VFA by CT (r=0.20; p=0.045). For sarcopenia, SMM by BIA was strongly correlated with SMM by CT (r=0.78; p<0.001).
In EPI-AP patients, a significant decrease of WHR (t(52)=2.262; p=0.028) and TFM (t(53)=1.695; p=0.046) by BIA was observed after 6months of PERT.

Conclusion

Body composition is significantly changed in AP, with >2/3 of patients with obesity, especially the visceral component. Obesity, including visceral obesity, correlates with AP severity. Obesity, including visceral obesity and sarcopenia are correlated with the EPI-AP and its severity, while sarcopenia is correlated with EnPI-AP. PERT has led to a significant reduction in obesity markers. Body composition assessment by BIA (TFM, VFA and SMM) and CT (VFA and SMM) were of clinical value and comparable.

References

1. Kim J, Kim S-s, Hwang HK, Kang CM, Kim KS, Kim SH. Body composition assessment using bioelectrical impedance analysis and computed tomography in patients who underwent pancreatoduodenectomy in Korea: a before and after study. Ann Nutr Metab 2023;15(3):72-80.
2. Wang S, Wang M, Jiang L, Zhao X. Low skeletal muscle quality extracted from CT is associated with poor outcomes in severe acute pancreatitis patients. Eur J Radiol 2024;170:111215.
3. Zhou Y, Hao N, Duan Z, Kong M, Xu M, Zhang D, et al. Assessment of acute pancreatitis severity and prognosis with CT-measured body composition. Int J Gen Med 2021;14:3971-3980.
4. Chaigneau T, Morello R, Vannier E, Musikas M, Piquet M-A, Vupont B. Impact of sarcopenic obesity on predicting the severity of acute pancreatitis. Did Liver Dis 2023;55(7):926-932.