Introduction

When it comes to removing large polyps during screening colonoscopies, general gastroenterologists often lack the necessary training and expertise. As a result, they will typically refer patients with large polyps to advanced endoscopists who have the required skill set to remove them. However, with the increasing number of techniques and approaches for removing large polyps, it is crucial for advanced endoscopists to have accurate information about the polyp in question in order to plan the best approach for its removal. Advanced endoscopists heavily rely on the referring doctor's information to begin this planning process, but unfortunately, many referrals for large polyps do not provide enough information to properly characterize the lesion. This can result in delayed care, mismanagement of the lesion, and may negatively impact the endoscopist's decisions in selecting the most appropriate resection technique and preparing the patient accordingly. Therefore, it is essential to establish standard guidelines regarding the necessary information to include in a referral for large polyps to ensure the best possible care is provided.

Aims & Methods

Our study aimed to determine the minimum standards for referring large colorectal polyps for endoscopic resection by utilizing the Delphi methodology to obtain expert consensus. We recruited 24 international experts in endoluminal advanced endoscopy from various continents. Experts were selected based on their publication record in the last decade, recognition as key opinion leaders in relevant endoscopic societies, and their willingness to disclose self-identification data for recruitment equity and diversity. The study comprised three rounds of surveys to achieve consensus. The first round involved generating research-related items or claims to establish minimum expected standards for referral of large complex (>20mm) colorectal polyps for potential endoscopic resection. In the second round, the experts voted on the statements using a 5-point Likert Scale to reach consensus. Statements that did not achieve consensus were abandoned, and the remaining statements were presented again for voting. In the third round, the experts ranked the items on a scale of 1 to 10 to allow an overall gradation of importance for each individual item.

Results

A total of 24 experts from four continents (Oceania, North America, Europe, and Asia) participated in the Delphi study, with equal representation of female and male experts. After the first round, 44 item statements were generated and sent for voting in the second round, grouped as follows: Patient Demographics (3 questions), Patient Anamnesis (13 statements), Previous Endoscopy Findings (7 statements), Lesion Findings (10 statements), Conclusion and Outcomes (7 statements). Out of the 44 statements, only 18 achieved consensus after the second round. The consensus rates for the accepted statements varied slightly among the different continents, with some statements achieving variable consensus rates in the different regions.

Conclusion

Overall, our study highlighted the need for a balance between providing comprehensive information and ensuring the practicality and simplicity of the referral report. The experts emphasized the importance of relevant and objective parameters while avoiding unnecessary burden on referring physicians. The feedback provided valuable insights and considerations for refining the standards for the referral of large colorectal polyps, ultimately improving the quality of care for patients undergoing endoscopic resection.

References

1. Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic Polypectomy and Long-Term Prevention of Colorectal-Cancer Deaths. http://dx.doi.org/101056/NEJMoa1100370 2012;366:687–696.
2. Gupta N, Bansal A, Rao D, et al. Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointestinal Endoscopy 2012;75:1022–1030.
3. Burgess NG, Hourigan LF, Zanati SA, et al. Risk Stratification for Covert Invasive Cancer Among Patients Referred for Colonic Endoscopic Mucosal Resection: A Large Multicenter Cohort. Gastroenterology 2017;153:732-742.e1.
4. Peery AF, Cools KS, Strassle PD, et al. Increasing Rates of Surgery for Patients With Non-Malignant Colorectal Polyps in the United States. Gastroenterology 2018;154:1352.
5. Hassan C, Repici A, Sharma P, et al. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 2016;65:806–820.
6. Ahlenstiel G, Hourigan LF, Brown G, et al. Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointestinal Endoscopy 2014;80:668–676.
7. Kaltenbach T, Anderson JC, Burke CA, et al. Endoscopic Removal of Colorectal Lesions Recommendations by the US Multi-Society Task Force on Colorectal Cancer. 2020.
8. Monika Ferlitsch A, Moss A, Hassan C, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. | Endoscopy 2017;49:270–297.

Disclosure

1. DVR, CS, ZR, MT, TM, RS, AR, AO, CH, LAS, AS, AB, EDF, MK, MP, AA, KM, KK, SS, NG, KMP, JDM, CWT, GRM, SCG - The authors have no financial disclosures or conflicts of interest to declare.
2. AS - Consultant: Boston Scientific, Interscope, Medtronic, Olympus; Research Support: Boston Scientific, Fujifilm; Advisory board: Endosound
3. MJB - Research support for ethics approved studies from Cook Medical, Olympus medical and Boston scientific
4. PS – Consultant: Boston Scientific, Ambu, Erbe
5. DKR - Consultant: Olympus, Boston Scientific, Sabela, Norgine, Acacia, GI Supply; Ownership interest in Satisfai Health
6. UDS - Research, Consultant and Speaker: Olympus and Boston Scientific; Consultant and Speaker: Conmed, Cook, Medtronic

Introduction

Watch-and-Wait is an increasingly recognized non-surgical management option for rectal cancer patients achieving a clinical complete response (cCR) following neoadjuvant therapy. This approach aims to preserve organ function by avoiding surgery, but necessitates vigilant endoscopic surveillance, to detect local tumor regrowth¹ (LTR). The specific endoscopic features associated with regrowth remain incompletely defined.

Aims & Methods

We performed a retrospective analysis of patients monitored under the Watch-and-Wait program at Karolinska University Hospital², focusing on the endoscopic characteristics of LTR. As of December 2023, 145 patients who met the criteria for clinical complete response (cCR) were included.
The neoadjuvant treatment consisted of chemoradiotherapy (CRT) in 16 patients (11%), short course radiotherapy (SCRT) + chemotherapy in 69 patients (47.6%) and SCRT alone (5 x 5 Gy) in 60 patients (41.4%). The median age of the patients was 66 years (range 29-94), with 61.4% being male. The initial tumor stage was T1/T2 in 42 patients (29%) and T3/T4 in 103 patients (71%). The nodal stage was N0 in 35 patients (24%) and N+ in 110 patients (75.9%). The median follow-up period was 29 months (range 3-102 months).
Patients were monitored with rectal digital exams, flexible endoscopy, CEA measurements, and MRI every 3 months for 2 years, and then every 6 months thereafter. During endoscopy, narrow-band imaging (NBI) and NICE classification³ was utilized.

Results

Out of the 145 patients, 28 (19.3%) experienced LTR as of December 2023. The median time from the completion of radiotherapy to regrowth was 9 months (range 3-20 months). Regrowth was detected intraluminally by endoscopy in 23 patients (82.1%), while in 5 patients (17.9%), regrowth was detected on MRI but was not visible intraluminally.
The most common endoscopic features of regrowth included a NICE 3 pattern (n=16) and contact bleeding (n=16). Additional findings included polypoid tissue (n=13), ulceration (n=10), irregular surface (n=9), fibrin cover (n=9), stenosis (n=6), and submucosal nodules (n=5).

Conclusion

As regrowth occurs in at least one of five patients and most commonly with intraluminal findings, this study highlights the importance of meticulous endoscopic follow-up. Contact bleeding and NICE type 3 lesions observed with narrow-band imaging (NBI) were key endoscopic findings in patients with tumor regrowth, while polypoid lesions were observed in less than 50%. Combining endoscopic assessment with other modalities, such as MRI, is essential, as regrowth may be undetectable endoscopically in a proportion of patients.

References

1. Cerdan-Santacruz C, Vailati BB, Sao Juliao GP, Habr-Gama A, Perez RO. Local tumor regrowth after clinical complete response following neoadjuvant therapy for rectal cancer: what happens when organ preservation falls short. Tech Coloproctol 2023;27(1):1-9. DOI: 10.1007/s10151-022-02654-5.
2. Nilsson PJ, Ahlberg M, Kordnejad S, Holm T, Martling A. Organ preservation following short-course radiotherapy for rectal cancer. BJS Open 2021;5(5). DOI: 10.1093/bjsopen/zrab093.
3. Hamada Y, Tanaka K, Katsurahara M, et al. Utility of the narrow-band imaging international colorectal endoscopic classification for optical diagnosis of colorectal polyp histology in clinical practice: a retrospective study. BMC Gastroenterol 2021;21(1):336. DOI: 10.1186/s12876-021-01898-z.

Disclosure

Stephan Haas (SLH) has received speaker's honoraria from Santax Medico, Tillotts Pharma, Lilly, Mediahuset, and Johnson & Johnson.

Introduction

Intestinal point-of-care ultrasound, as standardized by the International Bowel Ultrasound Group (IBUS), has emerged as a valuable tool for diagnosing, monitoring, and managing patients with Inflammatory Bowel Disease (IBD). While IBUS emphasizes a structured intestinal assessment, some European centers adopt a more comprehensive approach, combining intestinal ultrasound with a complete abdominal examination.
The Karolinska Centre for Digestive Health, a tertiary referral institution providing specialized care to approximately 4,500 patients with IBD, established a dedicated Gastrointestinal Ultrasound Unit in October 2023. This unit offers advanced diagnostic services to both hospitalized patients and those treated on an outpatient basis.

Aims & Methods

This retrospective study aimed to assess the prevalence of secondary extraintestinal findings in IBD patients undergoing comprehensive abdominal ultrasound between October 4, 2023, and March 4, 2025. All patients underwent ultrasound assessments that included both intestinal and abdominal imaging. Patients referred for indications unrelated to intestinal ultrasound (IUS), as well as those undergoing repeat examinations, were excluded from the analysis to ensure data consistency.
All examinations were performed by a single gastroenterologist with 25 years of ultrasound experience. In cases where secondary extraintestinal findings were identified, patients’ electronic medical records were reviewed to determine whether these findings represented new diagnoses or previously known conditions.

Results

The study included 348 patients with IBD, 201 (58%) females and 147 (42%) males, with a mean age of 42.4 years. Among these, 260 (75%) were referred internally by our IBD Outpatient Clinic, 47 (13%) by the Gastroenterology Ward, 33 (10%) by private outpatient clinics, and the remainder from other healthcare sites. IUS revealed evidence of intestinal inflammation in 144 patients (42%), while findings were normal in 204 patients (58%).
Furthermore, 150 patients presented with a total of 195 secondary extraintestinal findings, of which 113 (58%) represented newly identified pathologies. Among all secondary findings, the majority, 104 (53%), were related to the hepatobiliary system, including 33 newly diagnosed cases of hepatic steatosis and 17 new cases of cholecystolithiasis. One patient demonstrated ultrasound features suggestive of primary sclerosing cholangitis (PSC) and is currently undergoing further evaluation. Additional findings involved the reproductive system (29/15%), urinary system (15/7%), spleen (32/16%), and pancreas (5/2%). Various other intra-abdominal findings were also identified (37/18%). Notably, one patient presented with a suspicious mass in the right iliac fossa, and another demonstrated ultrasound findings suggestive of a prostatic tumor; both cases were referred for further oncologic evaluation. Additionally, three patients were newly diagnosed with intraductal papillary mucinous neoplasm (IPMN), which was subsequently confirmed via magnetic resonance imaging, and all were enrolled in the national IPMN surveillance protocol.

Conclusion

A considerable proportion of patients with IBD were found to have previously unknown extraintestinal abdominal pathologies, underscoring the essential role of comprehensive ultrasound examination that combines both intestinal and abdominal assessment. Fortunately, only a minority of these findings resulted in changes to patient management.

Disclosure

Francesca Bresso has acted as national and/or local principal investigator for clinical trials for Janssen, Ferring, and AbbVie. Charlotte Hedin served as a speaker and/or advisory board member for AstraZeneca, AbbVie, Dr. Falk Pharma and the Falk Foundation, Galapagos, Janssen, Pfizer, Ferring, Takeda, and Tillotts Pharma and received grant support from Tillotts Pharma and Takeda. Stephan L. Haas has served as a speaker for Takeda, Santax Medico, Tillotts Pharma, Johnson & Johnson, and Mediahuset. The rest of the authors have nothing to declare.

Introduction

T1 colorectal cancer can be managed either by surgery or interventional endoscopy. High-risk features after endoscopic resection (G3, submucosal invasion >1000 µm, lympho-vascular invasion, tumour budding+, or R1 resection) increase the risk of lymphnode metastasis (10-15%), often requiring additional surgery. However, the benefits of surgery versus endoscopic resection alone remain unclear, particularly in elderly or frail patients.

Aims & Methods

The aim of the study is to assess recurrence rate and overall survival in patients underwent surgery, endoscopy or both. Secondary endpoints is to evaluate incidence of adverse events and length of hospital stay
All consecutive patients diagnosed with T1 colorectal cancer from 2018 to 2024 in our institution were enrolled in this retrospective study. We divided this cohort in 3 groups: endoscopic resection plus surgery (ER-S), upfront surgery (SR), or endoscopic resection alone (ER). Demographics data, mortality, cancer recurrence rate, disease free survival and AEs were recorded.

Results

One-hundred and thirty-three patients were enrolled in the study: 34 (72 years±10) in the SR group, 65 (65 years±11) in the ER-S group and 34 (77 years±11) in ER, respectively.
Lesions were similar (p-value 0.30) for dimension: 31±15 mm (ER) vs 23±12 mm (ER-S) vs 30±13 mm (ER) such as follow-up (23 vs 24 vs 21 months) for the three groups (p-value 0.428). Hospital stay after the procedure was significantly lower in the ER group (1 day median) vs SR (median 9 days;p-value 0.0001) and ER-S group (7 days median;p-value 0.003). Cumulative 30 days adverse events were higher in the SR group (62%; p-value 0.0001) and in the ER-S group (22%; p-value 0.001) compared to ER alone (12%). During the study period, no endoscopic/radiological recurrence occurred in the SR group whereas 1 patient in the ER-S group and 2 in the ER group showed recurrence non suitable for further treatments.
Five patients in SR group died after a median of 18 months (1 for early surgical complication); 2 died in the ER-S group after a median of 34 months and 3 died in the ER group after a median of 24 months (1 for rectal cancer progression) (p-value 0.365).
Overall survival was comparable among the three groups with no significant difference (p-value 0.718) with a median of 40 months (SR), 28 (ER-S) and 26 (ER) months.

Conclusion

Endoscopic resection alone appears to be a reasonable option for high-risk T1 CRC patients, especially those with increased surgical risk due to low rate of recurrence, low adverse events and a comparable overall survival in short-mid term.

References

1. Quénéhervé, L.; Pioche, M.; Jacques, J. Curative Criteria for Endoscopic Treatment of Colorectal Cancer. Best Pract. Res. Clin. Gastroenterol. 2024, 101883, doi:10.1016/j.bpg.2024.101883.
2. Chen, Y.; Jing, W.; Chen, M.; Wang, Z.; Wu, J.; Yang, J.; Yang, L.; Deng, K. Long-Term Outcomes of Local Resection versus Surgical Resection for High-Risk T1 Colorectal Cancer: A Systematic Review and Meta-Analysis. Gastrointest. Endosc. 2023, 97, 1016-1030.e14, doi:10.1016/j.gie.2023.02.027.
3. Spadaccini M, Bourke MJ, Maselli R, et al. Clinical outcome of non-curative endoscopic submucosal dissection for early colorectal cancer. Gut. Published online January 20, 2022. doi:10.1136/gutjnl-2020-323897
4. Corre, F.; Albouys, J.; Tran, V.-T.; Lepilliez, V.; Ratone, J.-P.; Coron, E.; Lambin, T.; Rahmi, G.; Karsenti, D.; Canard, J.-M.; et al. Impact of Surgery after Endoscopically Resected High-Risk T1 Colorectal Cancer: Results of an Emulated Target Trial. Gastrointest. Endosc. 2023, S0016-5107(23)02933-4, doi:10.1016/j.gie.2023.09.027.
5. UICC. TNM. Classification of malignant tumours. eighth ed. Wiley; 2016. p. 272

Disclosure

Giuseppe Grande is consultant for Olympus, Boston Scientific, ERBE, Fujifilm

Introduction

Endoscopic removal of common bile duct stones (CBDS) via endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment. In developed countries, the number of ERCP procedures for CBDS in elderly patients is increasing with the aging population. Elderly patients often present with poor performance status (PS), are frequently on antithrombotic therapy, and have multiple comorbidities. These factors raise concerns about an increased risk of ERCP-related complications; however, the safety and efficacy of ERCP in this population have not been fully evaluated.

Aims & Methods

The aim of this study was to assess the outcomes of ERCP for CBDS in elderly patients. Among 548 patients with symptomatic CBDS treated at our institution between April 2017 and February 2024, we excluded 81 cases involving altered anatomy, use of endosonography-assisted rendezvous technique, spontaneous stone passage, and biliary pancreatitis. The remaining 467 patients undergoing ERCP at our institution were retrospectively analyzed. The patients were divided into an elderly group (E group: ≥75 years, n=241) and a younger group (Y group: <75 years, n=226), and short- and long-term outcomes were compared between the two groups.

Results

Patient Characteristics: The median age was 81 years (range: 75–99) in the E group and 68 years (range: 21–74) in the Y group. Male sex was less frequent in the E group (55% vs. 68%, p=0.006). The E group had significantly higher rates of antithrombotic use (39% vs. 24%, p=0.001), American Society of Anesthesiologists physical status ≥ III (57% vs. 35%, p=0.001), and concomitant cholangitis (52% vs. 41%, p=0.012). Median stone size was slightly larger in the E group (8 mm vs. 6 mm, p=0.14), and the median bile duct diameter was significantly wider (10 mm vs. 9 mm, p=0.001). Comorbidities were more prevalent in the E group: cardiovascular disease (34% vs. 22%, p=0.004), hypertension (52% vs. 39%, p=0.004), malignancy (33% vs. 18%, p=0.001), and dementia (11% vs. 2%, p=0.001). Although endoscopic sphincterotomy (EST) was the most common papillary intervention in both groups, endoscopic papillary large balloon dilation (EPLBD) was more frequently performed in the E group (31% vs. 10%).Lithotripsy rates were similar between groups (22% vs. 16%, p=0.2).
Outcomes: Complete stone removal was achieved in 96% of the E group and 98% of the Y group (p=0.2). The median number of treatment sessions was 1 in both groups (range: 1–3, p=0.13). Overall complication rates were comparable (8% vs. 7%, p=0.63). In the E group, complications included pancreatitis (n=15), bleeding (n=5), perforation (n=1), and aspiration pneumonia (n=1); in the Y group, pancreatitis (n=10) and bleeding (n=5) were observed. No procedure-related mortality occurred in either group. There was no significant difference in the cumulative recurrence rate of stones after complete removal (p=0.29). Multivariate analysis using variables such as age, sex, presence of cholangitis, bile duct diameter, lithotripsy, and gallbladder stones revealed no definite predictors of recurrence.

Conclusion

Although recent studies have reported the potential utility of long-term biliary stenting in elderly patients, stent occlusion leading to cholangitis remains a concern. Repeated hospitalizations in elderly patients can decrease activities of daily living. Therefore, we prioritize complete stone removal in patients with a favorable long-term prognosis. This study demonstrates that even in patients aged 75 years and older, active treatment of CBDS via ERCP might be effective and safe.

Introduction

Tofacitinib, filgotinib, and upadacitinib, are Janus kinase inhibitors (iJAKs) approved for inflammatory bowel disease (IBD) treatment. Although no direct comparative studies exist, potential differences in efficacy and safety are attributed to in vitro-demonstrated affinity of each molecule for different JAK isoforms. JAK1 plays a crucial role in modulating cytokine-mediated immune responses, such as IL-6 and interferon, which are involved in inflammation and skin homeostasis. Its inhibition can promote conditions that may trigger acne.
Acne may be increased in iJAK-treated patients, meaning a clinical challenge for gastroenterologists.

Aims & Methods

A retrospective study was conducted at ten referral centers in Spain, including all IBD patients who had received iJAK therapy and had at least 3 months of follow-up. Demographic data, disease-related variables, and acne characteristics when appropriate, were collected. Univariate and multivariate logistic regressions were used to identify risk factors for acne; model discrimination was assessed by AUC.

Results

A total of 549 patients included: 258 (47%) were women; 354 (64%) had ulcerative colitis, 191 (35%) had Crohn’s disease and 1% had indeterminate colitis. Mean age was 41 years (IQR 30-52). 219 patients (40%) were treated with tofacitinib, 281 (51%) with upadacitinib, and 49 (9%) with filgotinib.
Ninety patients (16%) developed acne during iJAK treatment: 69% were mild, with only 4 severe cases (4%). Acne occurred early (median onset 42 days, IQR 7-122), predominantly on the face (56%), trunk (13%) or both (31%). Acne morphology included comedones (60%), papules (59%), pustules (39%), nodular-cystic (12%), scarring (9%); 48% showed more than one morphology.
Thirty-six patients received specific acne treatment: 89% topical (antiseptics, benzoyl peroxide, retinoids), 69% systemic (antibiotics, retinoids, antiandrogens), and 44% combined treatment. 83% of those patients responded to acne specific treatment, and only 8 patients (9% of those with acne; 1.5% overall) had to discontinue iJAK treatment, with acne resolving in all cases.
Acne developed in 26%, 6% and 6% of upadacitinib, tofacitinib and filgotinib treated patients respectively (p=0.001). Multivariate analysis showed that acne development was associated with upadacitinib (OR 10.28;IC95%=4,7–22,6; p<0,001) and history of acne (OR 3.52; IC95%=1,5–8,3; p=0,004), while older age (>35 years, OR 0.31; IC95% 0,11–0,83; p=0,02) and Crohn’s disease (OR 0.47; IC95% 0,25–0,90; p=0,02) showed to be protective. This model was reliable in predicting acne development (AUC 0.79). Additionally, univariate analysis showed high dose of iJAK was also associated with acne development, which could not be confirmed in multivariate analysis.

Conclusion

Acne occurred in a relevant proportion of iJAK-treated patients, was generally mild and manageable with dermatological care, and rarely required treatment discontinuation. Risk factors for iJAK-associated acne included use of upadacitinib (probably reflecting a greater affinity for JAK1) and history of acne, while older age and Crohn’s disease were protective.
Gastroenterologists should be aware of both likelihood and management of this specific adverse event when considering iJAK therapy.

Disclosure

Y G-L, MC, GB, ER, IB, DC, M B-dA, LM, I M-J, DG, IV have provided scientific advisory / participated in educational activities / received unrestricted research grants / received payments for lecturing from Johnson & Johnson, ​Takeda, Pfizer, Amgen, AbbVie, Lilly, AlfaSigma, Ferring, Gilead.