Clinical Case Summary

A 37-year-old woman with a history of heavy alcohol use (3–4 bottles of wine weekly) presented with abdominal pain and haematemesis. She had experienced intermittent abdominal pain for two years. On assessment, she was stable apart from mild tachycardia and epigastric tenderness; melaena was confirmed on rectal exam. Blood tests revealed severe anaemia (Haemoglobin "Hb" 40 g/L from a baseline of 154 g/L). Gastroscopy showed severe oesophagitis without active bleeding. Abdominal CT showed a hyperdense focus in the neck of the pancreas, raising suspicion of a neuroendocrine tumour. After blood transfusion, she was discharged (Hb 73 g/L) with plans for outpatient colonoscopy and endoscopic ultrasound (EUS) to characterise the pancreatic neck lesion.
Two days later, she was readmitted with recurrent haematemesis and a Hb drop to 56 g/L. She was stabilized and discharged again. The day after her discharge, she underwent an EUS examination in our unit. The EUS revealed signs indicative of chronic pancreatitis, as well as a thick-walled vascular structure measuring 20 mm, adjacent to the head of the pancreas. This structure appeared to originate from a posterior branch of the gastroduodenal artery, and was consistent with a pseudo-aneurysm eroding into the wall of the duodenum. A subsequent triple phase CT scan showed an increase in the size of the hyperdense focus in the neck of the pancreas, raising concern for a pseudoaneurysm near the pancreaticoduodenal artery. Following these findings, the patient underwent successful coil embolization of the pseudoaneurysm.
Conclusion: In patients with chronic alcohol use, upper gastrointestinal bleeding (UGIB) may arise from complications of pancreatitis, such as pseudoaneurysm formation, rather than solely intraluminal causes. This case highlights the need for early identification and intervention in such rare but potentially life-threatening conditions.

Introduction

Distal malignant biliary obstruction (dMBO) is a frequently occurring condition that requires immediate intervention. The primary treatment for dMBO comprises endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent insertion^​. The European Society of Gastrointestinal Endoscopy recommends the use of self-expandable metal stents (SEMS) for palliative drainage of dMBO because of their superior patency and reduced incidence of adverse events (AEs), including recurrent biliary obstruction, compared to those of plastic stents^​. Three types of SEMS are available: uncovered SEMS (UCSEMS), fully covered SEMS (FCSEMS), and partially covered SEMS. However, the ideal stent type for palliative drainage of dMBO remains undetermined. Several studies have compared UCSEMS with FCSEMS to determine which type is most appropriate for dMBO^​. In terms of patency, some prospective trials have shown that FCSEMS result in better outcomes^​; however, others have observed similar results with UCSEMS and FCSEMS^​. Most studies have primarily focused on pancreatic cancer cases; however, the pathophysiology of pancreatic cancer and that of nonpancreatic cancer differ significantly, resulting in inconsistent outcomes. Post-ERCP pancreatitis (PEP) is the most common and serious AE associated with the transpapillary placement of SEMS, with an incidence rate of up to 10.8%^​. Therefore, studies have aimed to identify the risk factors for PEP after SEMS placement. Compared to UCSEMS placement, FCSEMS placement may be more strongly linked to a higher risk of PEP because they block the pancreatic duct orifice more effectively. Additionally, nonpancreatic cancer has been identified as a potential risk factor for PEP^​. Therefore, FCSEMS placement for nonpancreatic cancer cases is associated with a significantly higher risk of PEP. We examined the safety of UCSEMS for dMBO caused by nonpancreatic cancer and observed a low PEP rate, even for nonpancreatic cancer cases^​. However, a comparison of UCSEMS and FCSEMS is still required because no studies have evaluated their use for dMBO caused by nonpancreatic cancer. Therefore, this study evaluated the efficacy and safety of UCSEMS and FCSEMS for palliative drainage of dMBO caused by nonpancreatic cancer.

Aims & Methods

This retrospective multicenter study included patients who underwent UCSEMS or FCSEMS placement for nonpancreatic cancer-induced dMBO at four centers between January 2010 and April 2024. Propensity score matching (1:1) of the UCSEMS and FCSEMS groups was performed. Technical and clinical success, AEs, recurrent biliary obstruction (RBO), time to RBO (TRBO), and overall survival (OS) of these groups were compared.

Results

No significant differences in technical success (100% for both), clinical success (100% for both), and TRBO (median: 311 days [UCSEMS] vs. 317 days [FCSEMS]; p=0.42) were observed between groups. Similarly, OS did not differ significantly (median: 432 days [UCSEMS] vs. 190 days [FCSEMS]; p=0.083). The incidence of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) of the UCSEMS group was significantly lower than that of the FCSEMS group (4.2% vs. 33%; p=0.023).

Conclusion

compared to FCSEMS, UCSEMS provided sufficient patency and reduced AEs associated with dMBO caused by nonpancreatic cancer. The cause of dMBO should be carefully considered when choosing the optimal stent. UCSEMS may be safer and more effective than FCSEMS for the treatment of nonpancreatic cancer cases.

Disclosure

Authors declare no conflict of interests for this article.

Introduction

Hirschsprung’s disease is caused by the absence of ganglia in the deep intestinal wall, leading to dysfunction [1]. Resection of the affected area is the only cure, so accurate margin detection is essential. Currently, intraoperative rapid pathology is used, requiring tissue sampling and staining, but each test takes over 30 min and may need multiple samples, sometimes delaying decisions up to 3 h. A quick on-site method to detect ganglia around 200 μm deep is needed.
Various methods, including confocal microscopy [2], have been studied, but issues remain, such as dye toxicity and limited depth (>200 μm) imaging.

Aims & Methods

For non-destructive and stain-free visualization of tissues, we focused on Near-Infrared Hyperspectral Imaging (NIR-HSI)[3][4]. Near-infrared light—particularly in the 1000–1400 nm range—exhibits high tissue penetrability and is effective for detecting deep tissues. In addition, the near-infrared region provides spectroscopic information based on molecular vibrations, enabling component analysis. NIR-HSI holds promise for the identification of cancer and other biological tissues without the need for fluorescence or external marking [4][5].
To implement NIR-HSI, we developed a novel microscopic optical system capable of guiding near-infrared light. The near-infrared light source, which combines a supercontinuum light source and an acousto-optic tunable filter, allows for the selection of arbitrary wavelengths and irradiation of the target by adjusting the applied voltage [6]. This configuration enables the acquisition of near-infrared spectral images (NIR-HSI) at arbitrary wavelengths.
For performance validation, ex vivo experiments were carried out using mouse intestine in which the nerve plexus was selectively labeled with GFP (Green Fluorescent Protein). In these experiments, near-infrared light ranging from 850 to 1400 nm was irradiated in 10-nm increments, and 77 spectral images were captured. As a reference, GFP fluorescence images were acquired in the same field of view as the near-infrared images. Based on the fluorescence images, annotations were performed to delineate the enteric nerve plexus, and near-infrared spectra were obtained from both the nerve and non-nerve regions. Furthermore, using pixel-wise spectral data, segmentation of the nerve regions was performed with a machine learning model, and the accuracy of identification was evaluated.

Results

The NIR images captured by the system showed nerve distributions and mesh-like patterns similar to those in the GFP images. Spectral differences were observed between nerve and non-nerve regions. This likely reflects tissue composition differences, as muscle tissue has higher transmittance and nerve tissue higher reflectance in the NIR range [4][5][6].
Segmentation based on spectral data successfully extracted nerve contours and distribution patterns, achieving ~80% classification accuracy.

Conclusion

To enable non-invasive, label-free visualization of deep nerve distributions, we developed a NIR-HSI microscope by integrating near-infrared hyperspectral imaging with a microscopic optical system. In mouse intestine experiments, spectral differences were observed between enteric nerve plexus and surrounding tissue. The results suggest that mesh-like nerve structures can be estimated and outlined using NIR images alone. Future work will focus on imaging human samples.

References

1. Taguchi, T.et al., “The incidence and outcome of allied disorders of Hirschsprung's disease in Japan: Results from a nationwide survey,” Asian Journal of Surgery, vol.40-1, pp.29-34, 2017.
2. Kobayashi, M., Sumiyama, K., Shimojima, N., Ieiri, S., Okano, H., Kamba, S., Fujimura, T., Hirobe, S., Kuroda, T. and Takahashi‐Fujigasaki, J., “Technical Feasibility of Visualizing Myenteric Plexus Using Confocal Laser Endomicroscopy,” Journal of Gastroenterology and Hepatology, vol.32(9), pp.1604-10, 2017.
3. S. Hayashi et al., “Near-Infrared Multispectral Imaging Rigid Endoscope System for High-Speed Target Identification Using LED Rotating Light Source”, Advanced Biomedical Engineering , Vol.14, pp.79-88, 2025.
4. Akbari, H et al., “Cancer detection using infrared hyperspectral imaging”, Cancer Science, Vol. 102, No.4, pp.852–857, 2011
5. Afromowitz,et al., “Multispectral imaging of burn wounds: a new clinical instrument for evaluating burn depth”, IEEE Transactions on Biomedical Engineering, Vol35, No.10, pp.842-850, 1988.
6. R. Fukushima et al., “Detection of Exposed Nerves in Two Individuals In Vivo and Unexposed Nerves Ex Vivo with Near-Infrared Hyperspectral Laparoscope,” 2024IEEE/SICE International Symposium on System Integration (SII), Ha Long, Vietnam, pp. 19-24, 2024.

Introduction

Pain in chronic pancreatitis (CP) varies between patients in pattern, severity, and psychological impact. CP pain assessment has been focused on intensity, missing the complexity. To address the importance of multidimensional pain evaluations, we aimed to identify pain phenotypes based on multidimensional pain assessments and examine their association with clinical factors.

Aims & Methods

We studied 248 patients with painful CP from Asia, Europe, and the USA. A cluster analysis was performed on patients with painful CP, including five pain dimensions from the COMPAT-SF questionnaire (severity, fluctuation, provocative factors, spreading pain, and qualitative descriptors). The resulting clusters were compared based on demographics and clinical data, including patient-reported outcomes and quantitative sensory testing.

Results

		Cluster 1	Cluster 2	Cluster 3	p-value​
Questionnaires	Quality of life	66.3 (22.5)	64.8 (27.7)	51.1 (24.6)	<0.001
	Catastrophizing	10.7 (11.2)	19.1 (12.4)	24.3 (13.0)	<0.001
	Anxiety	5.3 (4.1)	6.2 (4.2)	8.7 (4.5)	<0.001
	Depression	4.3 (4.3)	5.5 (4.6)	7.3 (4.7)	<0.001
	Sleep	5.0 (3.5)	5.9 (3.8)	7.5 (4.5)	<0.001
QST	PPDT sum, kPa	2284 (997)	1811.5 (574.6)	1640.1 (600.4)	<0.001
	PPTT sum, kPa	2909.6 (1247.3)	2227.1 (691.3)	2184.9 (903.2)	<0.001
	Temporal summation, abdomen	1.7 (1.8)	1.9 (1.5)	1.4 (1.8)	0.178
	CPM (%)	2.3 (18.3)	5.1 (23.7)	7.2 (17.7)	0.135

Three distinct pain phenotypes were identified in the cluster analysis. Cluster 1 (n=73) included patients with low-severity pain; Cluster 2 (n=80) was characterized by severe, fluctuating pain; and Cluster 3 (n=95) comprised patients reporting constant, severe pain. Patients in Clusters 1 and 2 reported low scores across the remaining dimensions, whereas Cluster 3 consistently scored higher. Quality of life and sleep were best in Cluster 1, declined in Cluster 2, and were lowest in Cluster 3 (both p<0.001). Scores for anxiety, depression, and catastrophizing increased progressively across clusters (all p<0.001). Sensory testing revealed a pattern of increasing hyperalgesia, with Cluster 3 showing the most pronounced responses (p<0.001).

Conclusion

The COMPAT-SF questionnaire identifies three pain phenotypes in CP. Greater pain severity and persistence correlate with increased hyperalgesia, higher psychological distress, and worse overall well-being.

Introduction

There is increasing recognition that effective resident training in gastrointestinal endoscopy should be provided by endoscopists who have received formal educational training in the teaching of endoscopy.¹ While the implementation of Training the Colonoscopy Trainers (TCT) courses has led to significant improvements in colonoscopy quality outcomes^2,3 and polyp detection rates,⁴ evidence regarding the impact of TCT participation on teaching performance and resident learning – both of which are main goals of faculty development initiatives – is still lacking. Therefore, the aim of the present study was to evaluate the effectiveness of TCT course implementation using Kirkpatrick’s model of training evaluation.

Aims & Methods

In this study, 24 gastroenterologists from a university hospital and two affiliated general teaching hospitals in the north-eastern educational region of the Netherlands, participated in a two-day TCT course. The course was evaluated at three levels of Kirkpatrick’s model: (a) post-course evaluations reflecting the initial reaction; (b) video analysis of endoscopy training in the workplace before and after the TCT course using the mini-Structured Training Trainer Assessment Report (mini-STTAR); (c) a post-course resident survey reflecting the impact on the home-environment. Descriptive statistics and non-parametric tests were used to analyse the effectiveness of the TCT course.

Results

The TCT course was well received by participants, they highlighted the use of a structured training framework as a strength. Video analysis of endoscopy training in the workplace demonstrated a significant improvement in post-course trainer performance, both at 1-3 months (T1) and 6-9 months (T2). Significant improvements were found in the overall mini-STTAR scores (p<0.001), and across most mini-STTAR items, particularly in the items related to the phase preceding the actual training (referred to as the Set) and the evaluation after completion of the training (referred to as the Closure). Regarding the actual training (referred to as the Dialogue), participants demonstrated a significant positive change in ‘guiding/deconstructing’ and ‘controlling’ (both at T1 and T2) and in ‘encouraging/praise’ (only at T2). Participants received significantly higher 5-point Likert scale ratings as ‘excellent trainer’ at T1 (mean 4.13) and T2 (mean 4.29), compared to baseline (mean 3.58, p<0.001). In the post-course survey, all residents (N=16) were satisfied with the supervision of endoscopy trainers in their teaching hospitals. Nine (56%) reported uniform endoscopy supervision among trainers, a significant increase compared to a pre-course resident survey (8%, p=0.034).⁵ Although residents reported that the frequency of a didactic Set and Closure did not increase, most respondents indicated that the implementation of the TCT course improved the setting of learning objectives, the provision of spontaneous feedback, guidance during difficult endoscopies, and the prevention of undesired scope takeover.

Conclusion

The implementation of a TCT course provided a structured and useful training framework, and enhanced trainer performance, particularly in the didactic pre- and post-endoscopy training discussions, as well as in guiding, controlling, encouraging, and providing spontaneous feedback during the training of residents in gastrointestinal endoscopy.

References

1. Antonelli G, Voiosu AM, Pawlak KM, et al. Training in basic gastrointestinal endoscopic procedures: a European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement. Endoscopy. 2024;56:131-150
2. Waschke KA, Anderson J, Macintosh D et al. Training the gastrointestinal endoscopy trainer. Best Pract Res Clin Gastroenterol. 2016;30:409-419
3. Gavin DR, Valori RM, Anderson JT, et al. The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut. 2013;62:242-249
4. Hoff G, Botteri E, Huppertz-Hauss G, et al. The effect of train-the-colonoscopy-trainer course on colonoscopy quality indicators. Endoscopy. 2021;53:1229-1234
5. Mousset RA, de Vos Tot Nederveen Cappel WH, Pierie JEN et al. Endoscopy training in the Netherlands: a national survey among gastroenterology residents. Endosc Int Open. 2022;10:E1548-E1554

Introduction

Endoscopic ultrasound (EUS) has been established as a fundamental diagnostic and therapeutic tool in the management of gastrointestinal and biliopancreatic diseases. However, its long learning curve, particularly for therapeutic procedures, adds a level of complexity to EUS learning. A dedicated therapeutic EUS simulator may help physicians acquire and refine technical skills before exposition to real-life cases.

Aims & Methods

We aim to assess the feasibility and preliminary feedback of an EUS simulator box for therapeutic EUS training. The EUS simulator box was used for 150 minutes on the first training day of a 3-day hands-on therapeutic EUS course held on the International Therapeutic Endoscopic Ultrasound Course (ITEC) at IHU Strasbourg. It includes a porcine visceral block placed inside a specially designed box, including esophagus, stomach, duodenum, pancreas, lymph nodes, liver, gallbladder, spleen and kidneys. It allows endoscopic and ultrasound visualization mimicking human anatomy and replicates pathological conditions such as ascites and intra-abdominal collections. Trainees performed various procedures on the simulator including fine needle aspiration (FNA), fine needle biopsy (FNB), lumen-apposing metal stents (LAMS) and plastic stents cysto-gastrostomies. After completing all the procedures, participants were asked to fill in an evaluation form, which included five questions assessing simulation realism and procedural practice, scored on a quality scale from 0 (not good) to 5 (excellent).

Results

Twelve participants with varying levels of EUS training (mean 6.5 years of hands-on experience) were included. A total of 25 procedures were completed on two EUS simulator boxes (FNB=9, FNA=2, Cystogastrostomy using plastic prothesis=4, Cystogastrostomy using LAMS= 10). Most participants (10/12, 91,6%) rated the realism of the simulation as high, giving scores of 4 or 5. Additionally, 75% (9/12) rated the practice quality for specific procedures as excellent. All participants agreed that the EUS simulator box should be included in the standard EUS training curriculum.

Conclusion

The EUS simulator box has a realistic anatomical correlation and ease of use, shows potential as an effective simulator for both basic and advanced therapeutic EUS procedures, reducing the use of live animals for medical training. Further studies with larger sample size are needed to validate its educational value and impact on clinical practice.

Introduction

Endoscopic submucosal dissection (ESD) demands a high level of endoscopic skill and extensive training, even for experienced endoscopists, with a particularly steep learning curve for colonic ESD. Over the last three years, the French Society of Digestive Endoscopy (SFED) has implemented a structured ESD training program. This study aimed to evaluate the effectiveness of the SFED ESD training program to achieve competency in ESD and to identify factors associated with it.

Aims & Methods

Participants who attended the SFED ESD training curriculum over the past three years were invited to join the study. After completing a standardized initial simulation training week, each participant was asked to document each ESD procedures performed in their training center, along with technical details for each (lesion size and location, en bloc resection, R0 resection status, and procedural complications). Additionally, participants completed an online survey to gather information about their practice environment, ongoing ESD activity, and demographic data (e.g., gender, age, prior endoscopy experience). Successful dissection was defined as en-bloc resection with free lateral and deep margins (R0) and no need for surgical intervention due to complications. The performance threshold for achieving proficiency in ESD was defined, in line with ESGE guidelines, as achieving an en-bloc resection rate of >90% and a complication-related surgery rate of <1%. The learning curve to reach these competence standards was assessed using the LC-CUSUM method.

Results

A total of 45 students participated in the study. The majority were men (70%), with a median age of 36 years. They practice endoscopy for 6 years (IQR 4-10) and 82% performed interventional endoscopy (ERCP and EUS).
A total of 2,068 ESD procedures were performed by the trainees. The median number of ESDs conducted post-training was 34 (IQR 22-66), with the majority being colorectal (42.9% rectal and 42.7% colonic). Lesions had a median size of 45 mm (IQR 34-60), with a resection speed of 17.4 mm²/min (IQR 10.5-26.5). En bloc resection and R0 resection were achieved in 93.6% and 85.8% of cases, respectively, with a surgical complication rate of 0.94%. The overall success rate of ESD procedures was 92.7%. Success was more likely in rectal (97%) than colonic (90.4%) procedures. 75% of the students were competent. Among those who reached competence, the median number of ESDs required was 45. Factors associated with competency were : ESD localization (rectum > colon), the age (HR 0.92 [0.86-0.99]; p = 0.03) and experience (HR 0.91 [0.84-0.99]; p = 0.03) were inversely correlated to the competency. Practiced in a high volume ESD center (>100 ESD/year) lead to reach competency faster (p =0.008).

Conclusion

This study provides the first assessment of the SFED ESD training program in France. Competence in ESD is reachable after appropriate training. A big experience is not needed to attempt ESD. Supervised training is essential, and seems easier in a high-volume center to achieve competence more quickly. These findings may help inform the selection of future candidates for ESD training to ensure effective skill acquisition and safe practice.

Disclosure

nothing to disclose