Introduction

Effective colorectal cancer prevention relies on the quality of screening colonoscopy examinations. Cecal withdrawal time is significantly associated with adenoma detection rate (ADR), which is an established quality indicator for screening colonoscopy. Therefore, we introduced a real-time cecal withdrawal timer (CWT) that alerts the physician of the elapsed time since cecal intubation.

Aims & Methods

An observational, retrospective, single-center study to evaluate CWT in screening colonoscopy tests. The CWT is activated by a vocal command when the physician achieves cecal intubation. Following activation, the elapsed time is audio-announced every minute until the end of the procedure. The ADR of colonoscopies with and without the CWT was evaluated following CWT implementation from January 2023 to February 2024. Moreover, the ADR of the entire department in this period was compared with the year before.

Results

Of 1,557 colonoscopies between January 2023 and February 2024, 908 (58.3%) were performed with the CWT with a median withdrawal time of 8.75 (IQR: 6.9-12.0) minutes. During this period, the CWT usage was greater than 50% in 11 out of 14 months. Considering only months with CWT usage over 50%, the ADR of colonoscopies with CWT was 28.3% compared to 19.2% in those without (p<0.001). Among physicians who performed at least 20 tests with and 20 tests without the CWT, 6 out of 8 demonstrated improved ADR with the cecal timer. Notably, the 2 physicians who did not improve ADR had baseline ADR exceeding 30%. The overall ADR of the department between January 2023 and February 2024 was 25.5%, compared to 26.2% in 2022 (p=0.704).

Conclusion

Initial findings of the CWT program suggest its potential in enhancing screening colonoscopy quality indicators, although long-term prospective follow-up is warranted.

Disclosure

Nothing to declare

Introduction

Symptomatic luminal stricture in Crohn’s Disease (CD) occurs in up to 20% of patients at the diagnosis and in more than 50% during their lifetime. A considerable percentage of patients often require further surgery for post-operative CD recurrence, with a consequent increased burden of short bowel syndrome. In this scenario, combining biological therapy with endoscopic balloon dilation (EBD) could potentially reduce this risk.

Aims & Methods

Our study aimed to evaluate the efficacy of EBD combined with biologic therapy in symptomatic gastrointestinal strictures in CD patients. We conducted a retrospective study including consecutive CD patients who underwent EBD for low gastrointestinal strictures from December 2015 until November 2022 at our tertiary IBD Center. Subsequent subocclusive/occlusive episodes, the need for steroids, and surgery due to CD stenosis were evaluated during a follow-up period of 6, 12 months, and 24 months.

Results

A total of 52 patients treated with EBD with an overall number of 55 strictures were included. The mean age was 46,8 (18-77) years. The median of disease duration was 9 (0-42) years. Among the total of 55 studied strictures: 14 (25%) in patients with active smoking, 21 (38%) with increased CRP values at the time of dilation, 43 (78%) had evidence of moderate or severe endoscopic disease activity with ulcerative lesions at stricture site. Anastomotic strictures accounted for 26 (47%) of all 55 strictures. The remaining 29 (53%) were de novo stricture: 8 (15%) ileal, 11 (20%) at ileocecal valve, 4 (7%) colonic, and 6 (11%) anal . Forty-two patients (76%) were under biologic therapy at the time of EBD and 2 (4%) started after EBD. EBD technical success was reported in 60% of the procedures, and no adverse events were recorded. After 6 months from EBD, at univariate analysis, increased CRP at the time of dilation resulted in a risk factor for the need for steroids (OR 14,63, IC 2,690 to 71,50; p-value = 0,0006, Table 2). Concomitant biological therapy, active smoke, and the presence of ulcerative lesions did not show a significant correlation with considered outcomes. After 12 and 24 months from EBD, concomitant biological therapy resulted in being a protective factor for surgery (OR 0,06; IC 0,005 to 0,502; p-value=0,0047), while subocclusive and occlusive events were less frequent in anastomotic strictures than ileal stenosis (OR 0,07; IC 0,005 to 0,651; p-value=0,0152).

Conclusion

In patients with CD undergoing EBD for intestinal CD stricture, concomitant biological therapy reduces the risk of surgery for CD stenosis recurrence. Further prospective and controlled studies are underway to confirm these observations.

Disclosure

Antonio Gasbarrini reports personal fees for consultancy for Eisai S.r.l., 3PSolutions, Real Time Meeting, Fondazione Istituto Danone, Sinergie S.r.l. Board MRGE, and Sanofi S.p.A, personal fees for acting as a speaker for Takeda S.p.A, AbbVie, and Sandoz S.p.A, and personal fees for acting on advisory boards
for VSL3 and Eisai. Daniela Pugliese received speaker fees from AbbVie, MSD, Takeda and Janssen, Pfizer; advisory board fees from Pfizer. Franco Scaldaferri i: advisory board for Abbvie, Janssen, MSD, Sanofi and Takeda; All the other authors have no conflict of interest to declare

Introduction

Biodegradable pancreaticobiliary stents provide an alternative to conventional stents and avoid the need for a repeat procedure for endoscopic removal. While use is not currently widespread in the United Kingdom, accepted indications for insertion include bile leaks, prophylaxis of post-ERCP pancreatitis and as a bridge to cholecystectomy after bile duct clearance. Evidence from small studies suggest biodegradable stents are safe and cost effective, however there are few prospective studies to guide best practice. Complications of biodegradable stents are also not well understood with limited, if any, data describing issues specific to these types of stent. In our hospital trust, biodegradable stents have been in use since 2019 and this study aims to describe trends in use including complications and provide a comprehensive summary experience to date.

Aims & Methods

The electronic record of all patients in two hospitals within Manchester foundation trust who underwent insertion of a biodegradable pancreaticobiliary stent were reviewed. The study period was between March 2019 and April 2023. Patient demographics, type of stent, indication for stent insertion, readmissions and repeat ERCP data was collected on review of each patient’s record.

Results

During the study period 66 Biodegradable stents were inserted in 63 patients of which 48 were pancreatic and 18 biliary. All pancreatic stents were inserted for post-ERCP pancreatitis prophylaxis, whilst 5 biliary stents were performed for bile leaks and 13 for biliary drainage post-ERCP. A total of 9 patients were readmitted within 6 months for a pancreaticobiliary related complications including cholangitis (n=3), cholecystitis (n=2), post-ERCP pancreatitis (n=2), biliary obstruction (n=1) and persistent bile leak (n=1). In total, 10 patients underwent repat ERCP within 6 months. In one patient, the biodegradable stent was noted at ERCP to be in situ ERCP 5 months after insertion. Over 94% (n=17) of all biliary stents were performed in the first year of study, although the majority of these were inserted in 1 of the 2 study centres.

Conclusion

To our knowledge this is the largest series of patients undergoing biodegradable stent insertion in the United Kingdom. In this study, the most common indication for the insertion of a biodegradable stent was post-ERCP pancreatitis prophylaxis. As the study period progressed pancreatic stents became by far the most commonly inserted stent. In fact, only 1 biliary stent was placed in the final 3 years of the study period, demonstrating a trend towards the use of pancreatic biodegradable stents versus biliary stents. This may represent differences in clinical practice, services provided over time (e.g Spyglass or ‘hot’ cholecystectomies) or simply endoscopist preference. The study suggests that biodegradable stents are safe and effective with only 10 patients undergoing a further ERCP in 6 months. Therefore, a significant proportion of patients were able to avoid a second procedure thus providing a benefit in both risk and cost.

Disclosure

None

Clinical Case Summary

Superior mesenteric artery (SMA) syndrome is a rare cause of upper gastrointestinal obstruion.Nutcracker syndrome occurs as the result of external compression of the left renal vein. Although they share a similar pathophysilogy,occurring simultaneously is rare.
Case report 1: 41 years old female presented with chronic postprandial upper abdominal pain, frequent vomiting and marked weight loss.Barium meal showed thickened gastric and duodenal mucosa.Post contrast triphasic CT abdomen followed by 3D CT angiography revealed: dilated stomach, decreased aorta- SMA distance 5.5 mm& decreased aorta – SMA angle 20 degrees, compressed dilated left renal vein between aorta and SMA. She started conservative treatment with dietitian to gain more weight which relieved the pain and decreased vomiting episodes.
Case report 2: 16 years old female presented with persistant vomiting.Upper endoscopy showed dilated stomach with superficial erosions. CT aortic angiography revealed: reduced aorto mesentric angle to 19.8 and aorto mesentric distance reduced to 3.5 cm, proximal dilatation of the stomach, compression of left renal vein between aorta and SMA as well as mild dilated tortous ovarian and pelvic veins.Conservative treatment failed at first and due to refusal of surgery, she was sent for nasojejunal tube to optimize nutrition.
Case report 3: 36 years female patient presented with acute onset abdominal pain, vomiting with history of marked weight loss due to abdominal pain with attacks of hematuria. Barium meal and endoscopy suggested superior mesentric artery syndrome. CT angiography of the abdomen was ordered and showed decreased aorto mesentric angle to 16 and aorto mesentric distance to 2.8 cm, as well as compression of left renal vein between aorta and SMA suggesting SMA syndrome and nutcracker syndrome. Patient refused conservative treatment and refered for gastrojejunostomy and stent placement in the left renal vein for relief of obstruction of nutcracker syndrome.

Introduction

Endoscopic interventions in children require specialized training and expertise due to unique anatomy and physiology challenges. Pancreaticobiliary endoscopies represent highlighted procedures in this population due to the often-unusual indications and the inherent high risk of complications.

Aims & Methods

The current work demonstrates our experience in pancreaticobiliary endoscopy in the pediatric population. We retrospectively analyzed data on all patients <18 years old who underwent endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS) from 2021 to the present days at our department. We collected demographical data, indications, procedural findings, interventions, and complications.

Results

Overall, 19 ERCPs and 7 EUS procedures were performed on 24 children with regular endoscopes. 15 were males, and the mean age was 10.7 years (±4.7). Indications for ERCP included bile duct stones, benign stricture, pancreatic divisum and disconnected duct syndrome. Successful intervention was carried out in 18 cases, while there was one case of unsuccessful deep pancreatic duct cannulation due to abnormality of the duct. There was one case of perforation (Stapfer II), which was effectively managed endoscopically by placing a fully covered self-expanding metallic stent. 1 case of mild post-ERCP acute pancreatitis occurred following ERCP. EUS was performed for chronic pancreatitis, pancreatic cystic neoplasia, acute necrotizing pancreatitis, biliary compression and polycystic pancreas. 3 tissue acquisitions were done and one EUS-guided transluminal drainage was established. There were no complications.

Conclusion

To our knowledge, this is the most comprehensive domestic dataset of pancreaticobiliary endoscopies in children. Our findings imply that ERCP and EUS are effective diagnostic and treatment modalities in pediatric patients with acceptable safety profiles.