Introduction

Patients with inflammatory Bowel Diseases (IBDs) often present with inadequate control due to the limited efficacy of current treatments and suboptimal disease management. The IBD-PODCAST study aimed to estimate the proportion of Crohn´s Disease (CD) and Ulcerative Colitis (UC) patients with Inadequate Disease Control (IDC) based on the STRIDEII1 recommendations and assess the impact on their Quality of Life (QoL), in Portugal.

Aims & Methods

A non-interventional, multicenter study with a cross-sectional and retrospective assessments was conducted in Portugal gathering data from 130 patients (67 with CD, 63 with UC), from 5 Portuguese sites. The study collected real-world data of IBD patients regarding treatment and symptoms according to the STRIDE-II recommendations, to estimate the proportion of IBD patients with IDC. Patient’s QoL was assessed with the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). Analysis was descriptive in nature and performed separately for CD and UC.

Table 1: Definition of IDC based on STRIDE II with Cut-offs based on External Expert Panel

Results

The 130 patients had a mean age of 41.9 (14.3) years and 74 (56.9%) were males. Ileocolonic CD was present in 26 (38.8%) patients and 26 (41.3%) of UC had extensive colitis. Regarding treatment, 55 (82.1%) patients with CD and 34 (54%) with UC were on targeted immunomodulators (biologics and small molecule drugs) and, according to STRIDE-II therapeutic windows, 85.1% of CD and 92.1% of UC patients were on treatment long-term phase. 56.7% (38/67) of CD and 31.7% (20/63) UC patients presented IDC and according to SIBDQ, 50% of CD and 35% of UC IDC patients showed impaired QoL.

Conclusion

This study presents the current status of treatment options and management of IBD patients in Portugal, and overall indicate a high proportion of IDC both in UC and CD, indicating the continuous need for strategies to improve long-term outcomes and QoL in IBD.

References

1. Turner D, et al.; International Organization for the Study of IBD. STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining Therapeutic Goals for Treat-to-Target strategies in IBD. Gastroenterology. 2021 Apr;160(5):1570-1583.

Disclosure

H. Tavares de Sousa has received fees from AbbVie, Biogen, Ferring, Janssen, Pfizer and Takeda; P. Ministro has received fees from Abbvie, Ferring, Janssen, Pfizer, Takeda and Tillots; L. Correia has received fees from AbbVie, Ferring, Janssen, Pfizer and Takeda; S. Bernardo has received fees for presentations from Abbvie, Janssen and Takeda; J. Torres has received speaker bureau, advisory board fees from AbbVie, Janssen, Pfizer and BMS and Grant support from AbbVie and Janssen; F. Magro has received fees from AbbVie, Biogen, Falk, Ferring, Galapagos, Janssen, Lilly, Pfizer and Takeda. V. Martins, C. Rodrigues, C. Nascimento, S. Lopes, C. Oliveira have declared no conflict of interests. R. Prata, C. Leitner and T. Heatta-Speicher are AbbVie employees and may own stock or options.

Introduction

Gastrointestinal involvement is common in patients with multiple sclerosis (MS). It is estimated that 35–54% of MS patients experience constipation, while 29–51% develop faecal incontinence (FI), with both conditions frequently coexisting¹. The underlying pathophysiology is complex, as MS can affect the central nervous system at multiple levels. Despite its high prevalence and significant impact on quality of life, few studies have specifically addressed anorectal dysfunction in these patients.
The aim of our study was to describe the clinical and manometric features of MS patients presenting with constipation and/or FI.

Aims & Methods

26 patients with MS were included. High-resolution anorectal manometry (HRAM; Medtronic®), following the London protocol, and balloon expulsion test (BET; Matla Systems®) were performed in all subjects. Reference values were derived from 20 healthy controls assessed at our centre (Table 1).

Table 1. HRAM Parameters in Healthy Subjects in left lateral decubitus

Results

Faecal incontinence was observed in 21 patients (80.8%), predominantly mixed (42.3%), complete (stool and gas; 34.6%), and with Wexner scores >9 in 26.9% of cases. Constipation was reported by 15 patients (57.7%), of whom 14 (53.8%) perceived obstructive defecation. Constipation and FI coexisted in 10 patients (38%). Urinary incontinence was also present in 17 patients (65.4%).
Manometric findings revealed a tendency towards resting anal sphincter hypotonia (67.06 ± 19.85 mmHg) and reduced maximum voluntary contraction pressure (median 105.35 mmHg [IQR 86.48–149.28 mmHg]). Median contraction duration was 30 seconds (IQR 8–32 s). Rectal sensitivity assessment showed median thresholds for first sensation at 55 cc (IQR 40–70 cc), second sensation at 125 cc (IQR 100–160 cc), and maximum tolerated volume at 170 cc (IQR 135–190 cc). Sensory abnormalities were identified in 11 patients (42.3%), 4 due to hypersensitivity (15.4%) and 7 (26.9%) due to hyposensitivity.
An impaired push manoeuvre was observed in 20 patients (83.3%): type I dyssynergic defecation (DD) in 5 patients (20.8%), type II in 5 (20.8%), type III in 4 (16.7%), and type IV in 6 (25%). BET confirmed dyssynergia in 10 patients (41.7%).
*Note: Results are expressed as mean ± standard deviation or median (interquartile range), depending on data distribution. Reference values are presented as mean ± standard deviation.*

Conclusion

FI was the most prevalent symptom, often coexisting with constipation and obstructive defecation. The tendency observed in manometric findings towards anal hypotonia and hypocontractility, as well as the presence of dyssynergia in a significant number of patients, may allow the selection of individuals suitable for targeted therapies.

References

1. Dibley L, Coggrave M, McClurg D, Woodward S, Norton C. "It's just horrible": a qualitative study of patients' and carers' experiences of bowel dysfunction in multiple sclerosis. J Neurol. 2017 Jul;264(7):1354-1361.

Introduction

Gastroesophageal reflux disease (GERD) is common after per-oral endoscopic myotomy (POEM). Selective sparing of oblique fibers (OFS) during POEM may reduce the incidence of reflux esophagitis after POEM.

Aims & Methods

Aim: In this study, we aim to compare the incidence of GERD between conventional (CM) versus oblique fiber sparing (OFS) techniques of endoscopic myotomy in cases with idiopathic achalasia.
Methods: Eligible patients with type I and II achalasia who underwent POEM from Jan 2020 to October 2020 were randomized into two groups (CM and OFS). Exclusion criteria were: type III achalasia, sigmoid esophagus and history of Heller’s myotomy with fundoplication. The primary outcome of the study was comparison of reflux esophagitis in the two groups. The secondary aims included reflux symptoms, esophageal acid exposure, and clinical success.

Results

115 patients were randomized in CM (58) and OFS (57) groups. Both the groups were similar with regards to the symptom scores, sub-types of achalasia and history of previous treatment. The mean operation time was similar in both the groups (CM 43.7±23.8 mins versus OFS 46.4±24.7 mins). Mean length of total myotomies were comparable in the two groups (9.9±3.0cm vs 9.5 ±3.1cm). Clinical success (Eckardt≤3) was recorded in all the patients. Overall, reflux esophagitis was found in 56 (48.7%) patients. Grade B or higher esophagitis was similar in the two groups (25.9% vs 31.6%, p=0.541). The mean number of reflux episodes (48.2±36.6 vs 48.9±40.3, p=0.933), proportion of patients with increased esophageal acid exposure >6% (45.5% vs 31.7%, p=0.266) and high DeMeester scores (>14.7) (38.6% vs 41.5%, p=0.827) were similar in both the groups. Symptomatic GERD (GERDQ>7) and use of PPIs at 1-year was similar in the two groups (GERDQ>7: 29.8% vs 26.5%, 0.822)(PPIs: 34% vs 28.6%, p=0.661).

Conclusion

Sparing of sling fibers has no significant impact on the incidence of GERD after POEM. Novel strategies need to be explored to prevent GERD after POEM. (NCT04229342)

Disclosure

No disclosure

Introduction

Endoscopic submucosal dissection (ESD) is a valuable technique for the en-bloc resection of superficial neoplasms in the anal canal. However, its safety and efficacy in patients who have previously undergone transanal endoscopic surgery (TES) —such as transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery (TEM)—remain unclear.

Aims & Methods

To assess the safety and outcomes of ESD in the anal canal for patients with a history of TES compared to naïve patients.
A retrospective analysis was conducted at our tertiary center on 51 patients who underwent ESD in the anal canal between March 2010 and November 2024. Patients with a history of transanal endoscopic surgery were compared to those undergoing ESD as their primary treatment. Key parameters, including resection speed, perforation rates, coagrasper usage, inpatient status, late hemorrhage, and recurrence, were evaluated. Statistical analysis was performed to determine significant differences between groups.

Results

Histological examination confirmed the following cases: 3 adenocarcinomas (including 1 non-curative ESD), 15 adenomas with high-grade dysplasia, 11 adenomas with low-grade dysplasia, 2 sessile serrated lesions, 15 sessile serrated lesions with dysplasia, 2 high-grade intraepithelial lesions, 2 low-grade intraepithelial lesions.
The median resection velocity was slightly lower in patients with recurrence (16.01 mm²/min) compared to those without recurrence (25.56 mm²/min), though this difference did not reach statistical significance (p = 0.062). Perforation occurred in 9.62% of cases, with similar rates between groups (p = 0.58), suggesting that prior TEM does not significantly increase the risk of this complication. Late hemorrhage was observed in 7.84% of patients, again without a significant difference between groups (p = 0.29).
The only statistically significant finding was the smaller lesion size in patients with recurrence (1,162 mm² vs. 2,250 mm², p = 0.045). This is likely due to intensive post-TEM surveillance, which allowed for early detection of recurrence before lesions could grow larger. Other factors, including sex, age, use of coagrasper during the procedure, en-bloc resection, R0 status, and inpatient admission rates, showed no significant differences between groups.

Conclusion

ESD in the anal canal after prior TES appears to be a safe and feasible procedure, with outcomes statistically comparable to those in naïve patients. Although absolute numbers suggest differences, particularly in lesion size, these findings may be influenced by the small sample size. Larger studies are needed to confirm these results and further evaluate long-term efficacy.

Introduction

Third space endoscopic procedures like endoscopic submucosal dissection (ESD) and peroral endoscopic myotomy (POEM) are technically challenging and bear the risk of operator dependant complications such as bleeding and perforation. We aimed at developping and evaluating a deep learning algorithm for the real time detection and delineation of submucosal blood vessels during third space endoscopy.

Aims & Methods

We used 5.470 annotated endoscopic images from 59 full length ESD and POEM videos and 179.681 unlabeled images from the same procedures for the semi-supervised training of a DeepLabv3+ based neural network. The model detects and delineates submucosal blood vessels on endoscopic images in real time. The algorithm was tested on 101 standardized video clips with 200 predefined blood vessels derived from 15 separate third space endoscopy videos. Vessel detection rate, time and duration, defined as the percentage of single frames, on which the algorithm detected a defined vessel in relation to the gold standard were determined. Furthermore, the performance of 8 endoscopists plus or minus AI support with regard to blood vessel detection was evaluated.

Results

The mean Dice score for blood vessels was 68%. The overall vessel detection rate (VDR) of the algorithm was 94% (ESD 96%, POEM 74%). The median overall vessel detection time (VDT) of the AI algorithm was 0.32 sec (ESD 0.3 sec, POEM 0.62 sec). The mean overall vessel detection duration (VDD) was 59.1% (ESD 60.6%; POEM 44.8%) of the gold standard. All eight endoscopists had a higher VDR with AI than without. Mean VDR with AI was 71.2% and 56.4% without (p<0.001).

Conclusion

Regarding blood vessel detection, all endoscopists performed better with AI support than without. A vessel detection time of well under one second and a vessel detection duration of over 50% was considered adequate for clinical application. AI support was associated with a significantly higher vessel detection rate but in many cases a lower rate than AI alone. This was attributed to the subtle and in some situations not clearly visible delineation by the AI algorithm on the endoscopic image. In future prospective trials the AI algorithm should be evaluated for clinical relevance, i.e. lower complication rate and faster procedure time.

Disclosure

LHSL: GenieBiome Ltd. (research product support, lecture fees), Olympus Co. Ltd. (Lecture fees), Boston Scientific Co. Ltd. (Lecture fees)
PWYC: Cornerstone Robotics (Board Member), Endomaster Pte Ltd (Scientific Advisor), Boston Scientific Co Ltd (Research Collaboration), Olympus Co Ltd (Research Grant)