Introduction

Inflammatory bowel disease (IBD) imposes severe financial burdens in low-middle income countries (LMICs). Sri Lanka's healthcare system faces unique challenges in managing chronic diseases like IBD. This study evaluates financial toxicity (FT) using the validated FACIT-COST instrument.

Aims & Methods

This cross-sectional study aimed to quantify financial toxicity (FT) and identify risk factors among IBD patients at Sri Lanka's National Hospital. 132 IBD patients (68 Crohn's disease [CD], 64 ulcerative colitis [UC]) were recruited. Demographics, education levels, and disease characteristics were collected via structured interviews and medical records. FT was assessed using the 12-item 'FACIT-COST - Version 2' validated questionnaire (range: 0-44, lower = worse). Data was analyzed using Spearman's correlation and t-tests.

Results

The cohort's mean age was 40.55 ± 15.7 years, with a balanced gender distribution (males: 65 years, females: 67 years). The majority (62.8%) had completed secondary education or higher. The mean FT score was 19.44 ± 7.28, indicating a mild-to-moderate financial burden. FT was significantly higher in CD patients (mean = 20.65) compared to UC (mean = 18.16, p=0.049). Medication costs were the main financial concern for 75% of patients. FT scores correlated weakly but significantly with education level (rho=+0.229, p=0.008), suggesting higher education modestly reduces financial toxicity. No correlation was found with age of onset or diagnostic delay (mean = 851 days).
A notable proportion reported significant financial hardship (FT-12: 47%), and 35.6% felt IBD reduced satisfaction with their financial situation. The mean age of onset differed markedly by disease type: CD patients presented earlier (males: 23.1 years; females: 23.9 years) than UC patients (males: 32.4 years; females: 37.1 years).

Conclusion

IBD imposes a significant financial burden, particularly in patients with Crohn’s disease, who face both earlier onset and higher toxicity. Targeted interventions should include:
(1) subsidies for high-cost drugs,
(2) patient education programs,
(3) improved accessibility of hospital medications,
(4) quality enhancement of available treatments,
(5) local guidelines for resource-limited settings, and
(6) establishment of IBD support groups.
These systemic solutions are essential to mitigate financial distress and improve the quality of life for Sri Lankan IBD patients.

Introduction

Endoscopic submucosal dissection (ESD) for early upper gastrointestinal (GI) tumors creates large mucosal defects with risks of bleeding, perforation, and strictures, particularly in the esophagus where post-ESD stricture rates reach clinically significant levels. Current closure methods are inadequate for managing esophageal defects due to anatomical complexity. We present an endoscopy-integrated platform for real-time in situ nanofiber deposition during upper GI ESD, leveraging blow spinning technology to address these limitations.

Aims & Methods

This study aimed to
(1) engineer a coaxial nozzle system compatible with standard upper GI endoscopes (working channel ≤3.7 mm),
(2) optimize nanofiber deposition parameters for esophageal wound repair, and
(3) validate therapeutic efficacy in preclinical models.
A simplified in vitro setup was used to optimize polymer composition (polycaprolactone/gelatin blends), gas pressure (0.2-0.5 MPa), and blowing distance (10-20 cm). A murine skin wound model was employed to validate nanofiber adhesion and repair properties. For endoscopic integration, a dual-layer coaxial nozzle was designed using computational fluid dynamics (CFD), featuring an inner polymer delivery channel (0.5 mm inner diameter) and an outer airflow channel (1.2 mm inner diameter) to generate nanofibers via controlled airflow. The nozzle was fabricated using stereolithography 3D printing with biocompatible resins and integrated into a compact endoscopic system. Functional testing was performed in a transparent esophageal phantom under simulated physiological flushing, followed by in vivo validation in a porcine esophageal ESD model comparing nanofiber-treated wounds to controls.

Results

The 3D-printed coaxial nozzle (3.0-mm outer diameter) demonstrated full compatibility with standard upper GI endoscopes. In simulated esophageal conditions, the platform achieved uniform nanofiber deposition (fiber diameter: 15.2±3.6 μm) with robust adhesion unaffected by luminal flushing. In the porcine esophageal ESD model, immediate nanofiber application provided complete wound coverage, reduced perioperative bleeding, and prevented stricture formation. Histological analysis at 4 weeks revealed markedly reduced fibrosis and enhanced mucosal regeneration in treated groups compared to controls. The system operated seamlessly within the standard ESD workflow without procedural interference.

Conclusion

This study develops the first endoscopy-compatible platform for real-time in situ nanofiber deposition, demonstrating preclinical efficacy in addressing post-ESD complications in the upper gastrointestinal tract. By synergizing mechanical barrier formation with bioactive healing modulation, the technology reduces stricture risks and promotes mucosal repair in porcine esophageal ESD models. While current findings underscore its translational promise, further optimization of biomaterial formulations and rigorous human trials are essential steps toward clinical adoption in therapeutic upper GI endoscopy.

Introduction

Anorectal dysfunction affects approximately 8% of the global population.¹ Whilst conservative management can manage mild symptoms, surgery is often indicated in patients with structural abnormalities and severe symptoms. A Magnetic Resonance Imaging Defecating Proctogram (MRDP) forms a key part of patients’ pre-surgical investigations, visualising the anterior, middle and posterior compartments of the pelvis, and provides a dynamic image of the pelvic floor during defecation. It has been criticised as it is often performed in the supine position, which does not reflect normal physiological positioning for defecation.² However, little is known about how patients themselves feel about how this test reflects their usual defecatory process.

Aims & Methods

As part of a service evaluation, between September 2024 and April 2025, all patients who underwent an MRDP at Imperial College Healthcare NHS Trust in London, United Kingdom, were asked to complete a 21-item questionnaire exploring their experiences, prior to, during and after their MRDP. Five-point Likert Scales (1 - Strongly Disagree, 5 - Strongly Agree) were used for each question, except two concluding questions on overall experience, which were answered using free-text boxes. Patients with insufficient cognitive function or comprehension of English to complete the questionnaires were excluded.

Results

Thirty-eight patients responded to the questionnaire, and after excluding those with missing data, 35 completed questionnaires were included in the analyses (30[86%] female, 28[80%] 50-79 age category). Reasons for referral to MRDP included FI (15/35 [43%]) and/or constipation (13/35 [37%]) and/or POP (9/35 [26%]). Although 32(91%) strongly agreed that their privacy was respected, and none strongly agreed they felt embarrassed, just 12(34%) strongly agreed that they felt ‘comfortable during the test’. Less than a third of patients (10[29%]) agreed that they were able to ‘defecate as they do at home’ and only a quarter (9[26%]) felt that defecating lying supine was easy. Whilst 16(46%) patients felt that the contrast mixture inserted gave them a ‘normal urge to open their bowels’, only 4(12%) reported that the contrast mixture was ‘similar to their own stool’. Nevertheless, 23(66%) patients agreed that the experience matched what they would expect, and most patients (29[83%]) would have the test again if it were necessary. Patients aged 70-79 were associated with disagreeing with the statement that they could ‘defecate as they would at home’ (neutral/disagree/strongly disagree vs. agree/strong agree: 8/8[100%] vs 0.0[0%], p = 0.011).

Conclusion

Whilst patients reported being able to tolerate the MRDP, the large majority reported that defecating during the investigation did not reflect their usual defecatory process. Contrary to expectation, it appears that patients’ main complaints were not due to embarrassment, but rather patient position and environment. Whilst patient experiences are highly institution and staff dependent, understanding patients’ perspectives during an MRDP is useful for optimisation of pre-investigation counselling and expectation setting. Implementing post-MRDP questionnaires, or pro-active clinician exploration of the extent to which patients felt able to replicate their symptoms could facilitate clinical interpretation of MRDP results. Moving towards evacuation testing that aligns more closely with a patient's normal defecatory habits is likely to yield results that better reflect symptom profiles and therefore provide better insights into specific surgical targets responsible for symptom generation.

References

1. Jaafari H, Houghton LA, West RM, et al. The national prevalence of disorders of gut brain interaction in the United Kingdom in comparison to their worldwide prevalence: Results from the Rome foundation global epidemiology study. Neurogastroenterology & Motility. 2023; 35:e14574. doi:10.1111/nmo.14574
2. Pilkington, S.A., Nugent, K.P., Brenner, J., Harris, S., Clarke, A., Lamparelli, M., Thomas, C. and Tarver, D. (2012), Barium proctography vs magnetic resonance proctography for pelvic floor disorders: a comparative study. Colorectal Disease, 14: 1224-1230. https://doi.org/10.1111/j.1463-1318.2012.02945.x

Introduction

A grey zone known as the borderline resectable (BR) category, which lies between resectable and unresectable, has been proposed for perihilar cholangiocarcinoma; however, there is no international consensus on this classification. BR can be considered from various perspectives, including local tumor factors, surgical risk, long-term prognosis, liver reserve capacity, and systemic condition.

Aims & Methods

The study's aim is to define the borderline resectable (BR) of perihilar cholangiocarcinoma based on surgical procedure and preoperative liver function. We examined 1) the comparison of surgical outcomes between extended surgery and standard surgery and 2) the risk of postoperative mortality from liver failure in patients who underwent portal vein embolization.
Study 1) Surgical cases from January 2011 to December 2023 were divided into two groups: the Extended surgery group: left or right trisectionectomy(L3/R3), concomitant hepatic artery resection (AR), hepatopancreaticoduodenectomy (HPD), and the other standard surgery groups. Study 2) The risk of postoperative liver failure in patients who underwent resection after portal vein embolization (PVE) between January 2001 and December 2022 (including HPD) was evaluated

Results

Study 1) A total of 181 patients (59 in the extended surgery group and 122 in the standard surgery group) were included in the study. There were significant differences in operation time (median 798/700 minutes, p<0.01) and blood loss (2000 ml/1295 ml, p<0.01) in the extended surgery group compared to the standard surgery group, but no significant differences in postoperative complication rate (Clavien Dindo 3a or higher: 79%/67%) or in-hospital mortality rate (5%/5%). The 5-year overall survival rate was 34% in the extended surgery group and 50% in the standard surgery group, which was not significantly different by the log-rank test. Study 2: The incidence of liver failure (%) and mortality (%) by surgical technique were R (37/5.7), L3 (30/5), and R3 (54/7.7). ICGK x proportion of remnant liver volume（ICGKF）<0.05 before PVE, operation time >660 minutes, and blood loss >1900 ml were identified as risk factors in univariate and multivariate analyses, and the mortality rate for patients with these three factors was high at 25%.

Conclusion

Patients who required extended surgery with poor pre-PVE liver function (ICGKF<0.05) should be considered BR in perihilar cholangiocarcinoma.

References

1: Nooijen LE, de Boer MT, Braat AE, Dewulf M, den Dulk M, Hagendoorn J, Hoogwater FJH, Lam HD, Molenaar Q, Neumann U, Porte RJ, Swijnenburg RJ, Zonderhuis B, Kazemier G, Klümpen HJ, van Gulik T, Groot Koerkamp B, Erdmann JI.
National consensus on a new resectability classification for perihilar cholangiocarcinoma - A modified Delphi method. Eur J Surg Oncol. 2025 Feb;51(2):107117. PMID: 37880001.
2: Kuriyama N, Usui M, Gyoten K, Hayasaki A, Fujii T, Iizawa Y, Kato H, Murata Y, Tanemura A, Kishiwada M, Sakurai H, Mizuno S, Isaji S.
Neoadjuvant chemotherapy followed by curative-intent surgery for perihilar cholangiocarcinoma based on its anatomical resectability classification and lymph node status. BMC Cancer. 2020 May 11;20(1):405. doi: PMID: 32393197;.
3: Matsuyama R, Mori R, Ota Y, Homma Y, Yabusita Y, Hiratani S, Murakami T, Sawada Y, Miyake K, Shimizu Y, Kumamoto T, Endo I.
Impact of Gemcitabine Plus S1 Neoadjuvant Chemotherapy on Borderline Resectable Perihilar Cholangiocarcinoma.
Ann Surg Oncol. 2022 Apr;29(4):2393-2405. doi: 10.1245/s10434-021-11206-4. Epub
2022 Jan 7. PMID: 34994885.

Introduction

In laparoscopic cholecystectomy (LC), intraoperative cholangiography (IOC) is recommended to clarify biliary anatomy, detect choledocholithiasis and identify complications. IOC interpretation may be performed by either surgeons or radiologists, but it remains unclear which approach is preferable. This study investigates how the type of medical specialist interpreting the IOC affects surgical outcomes and operating time.

Aims & Methods

All LCs registered in the Swedish Registry of Gallstone surgery and Endoscopic retrograde Cholangiopancreatography (GallRik) between January 1, 2009, and December 31, 2020, were included. A complementary survey was distributed to all participating surgical clinics to determine local IOC interpretation practices. Registry and survey data were linked and outcomes were analysed using mixed model analysis and logistic regression.

Results

A total of 118.556 procedures from 61 surgical units were included. Operating time was longer when radiologists assessed the IOC (mean differences 11.3 minutes; 95% CI 1.60-20.89). Intraoperative complications were more common with radiologist interpretation (2.6% vs 1.5%; OR 0.58, 95% CI 0.52-0.63), while postoperative complications were slightly higher with surgeon-led interpretation (8.2% vs 7.3%; OR 1.14, 95% CI 1.08-1.20). Bile duct injury rates (0.3%; OR 1.0, 95% CI 0.79-1.27) and detection of choledocholithiasis (12.4% vs 12.6%; OR 1.02, 95% CI 0.90-0.99) were similar between groups.

Conclusion

Surgeon-led IOC interpretation is associated with shorter operating times and fewer intraoperative complications, without increasing the risk of bile duct injury or missed choledocholithiasis. Routine radiologist involvement may be unnecessary and an inefficient use of resources.

Introduction

Symptomatic uncomplicated diverticular disease (SUDD) is characterized by recurrent gastrointestinal (GI) symptoms in patients with colonic diverticula. Different treatments have been proposed to improve GI symptoms, but with low-level of evidence.

Aims & Methods

We aimed to evaluate the efficacy of a synbiotic formulation combined with a diet rich in fibre (DRF) in improving GI symptoms in SUDD, compared to a DRF and placebo. We conducted a single-centre, no-profit, randomised, double-blind, placebo-controlled trial (Local Ethics Committee n.182 SA_2020). Patients diagnosed with SUDD (colonic diverticula and recurrent abdominal pain with or without altered bowel habits or bloating, in the absence of signs of systemic inflammation) were included. After a 14-day run-in period, all participants completed structured questionnaires [long- and short-lasting abdominal pain, abdominal bloating, Rome IV for IBS, food frequency questionnaire and quality of life (SF-12)], received a dietary counselling, and were randomised to receive either (I) Enterolactis duo (containing the probiotic strain Lacticaseibacillus Paracasei DG and the prebiotic fibre inulin) 1 sachet bid plus advice on DRF (arm A), or (II) Placebo, 1 sachet bid plus advice on DRF (arm B) for 12 weeks. During treatment, patients completed a weekly diary of GI symptoms and bowel habits. At the end of treatment, patients completed all questionnaires again and were followed up after 4 weeks.

Results

After screening 81 patients, 34 (55.9% female; mean age 64±8.6yrs) were included and randomised to arm A (n=17) and arm B (n=17). At baseline, there were no significant differences in terms of clinical characteristics between the two arms. Thirty patients (arm A=14; arm B=16) completed the study. Compliance with the DRF was poor in both arms (0% vs 14.3%). Patients experienced significant improvements in GI symptoms (bloating, short- and long-lasting abdominal pain) and bowel habits compared to baseline in both arms, but no differences were observed between the two arms. Neither arm A nor arm B reported significant changes in the quality of life scores. Mild self-limited adverse events were reported with no differences between arms. Follow-up at 4 weeks showed no clinical changes in either arm, with no differences between arms.

Conclusion

This synbiotic supplementation is as effective as placebo in relieving symptoms in SUDD patients, suggesting the relevant role of the placebo effect also in diverticular disease.

Introduction

Idiopathic Sclerosing Mesenteritis (SM) is a rare fibroinflammatory disease of unknown etiology. The clinical course is generally benign, as has been demonstrated in retrospective studies and large case series.

Aims & Methods

To more accurately determine the natural history of patients with symptomatic SM and describe the clinical features of those with idiopathic SM, we performed a prospective cohort study. Inclusion criteria were adult patients with typical SM symptoms, after ruling out other causes of abdominal pain, who met the Coulier criteria in computed tomography scans for establishing SM diagnosis. We identified 58 patients with symptomatic SM. During the follow-up period, 3 patients were lost and excluded from the analysis. Most patients (95.7%) underwent upper and lower endoscopy and chest imaging to rule out co-existing cancer disease. Secondary SM cases were also excluded (n=5 had a co-existing cancer diagnosis within 6 months of SM diagnosis and n=4 had a pre-existing diagnosis of SM-related autoimmune disease at SM diagnosis). The final cohort of symptomatic idiopathic SM cases consisted of 46 patients. Data were collected prospectively at each site visit from January 2014 to January 2024. Descriptive statistics were used to summarize the results.

Results

In total, 46 patients with idiopathic SM were included, of whom 56.5% were females and 43.5% were males with a mean age at diagnosis of 62 years. Overweight or obese were 62.8%, and 37.2% had normal weight. SM was histologically confirmed in 13%. Features of IgG4-related disease were present in 21.7% with other organ involvement (13% pancreas, 10.9% bile ducts, 2.2% orbit, and 2.2% lymph nodes). Multiple organ involvement was observed in 6.5%. All patients who presented with an abdominal mass (8.7%) developed features similar to IgG4-related disease. Elevated serum IgG4 levels at diagnosis were found in 7 of 36 patients (19.4%). All patients presented with abdominal pain, followed by bloating (84.8%), nausea (43.5%), anorexia (39.1%), weight loss (37%), vomiting (30.4%), dyspepsia (19.6%), diarrhea (19.6%), constipation (13%), fever (8.7%), icterus (4.3%), early satiety (4.3%), sarcopenia (4.3%), and peripheral edema (2.2%). Hospitalization was required in 37%, and severe complications were observed in 30.4% [ileus (15.2%), acute pancreatitis (8.7%), acute cholangitis (8.7%), abdominal mass (8.7%), chronic pancreatitis (4.3%), mesenteric thrombosis (2.2%), and obstructive lymphadenopathy (2.2%)]. Surgical intervention was performed in 13%. During the disease course, most patients (84.8%) were treated with colchicine in combination or not with corticosteroids (54.3%), antiplatelets (50%), and low-molecular heparin (28.3%).

Conclusion

In this prospective cohort study, we observed an aggressive clinical course with severe intra-abdominal complications in a substantial proportion of patients with idiopathic SM (30.4%). Almost one in four patients (21.7%) manifested other organ involvement, identical to IgG4-related disease, indicating that some idiopathic SM cases could be part of the IgG4 disease spectrum. These observations suggest that idiopathic SM requires clinical vigilance similar to that applied to IgG4-related disease.

References

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Disclosure

No potential conflicts of interest