Introduction

^​Intestinal ultrasound (IUS) is gaining increasing acceptance as a reliable tool for tight monitoring of ulcerative colitis (UC). Although several IUS scores have been proposed, none has been formally implemented into official recommendations of international scientific societies.

Aims & Methods

We aimed to compare an IUS score validated for Crohn’s disease (CD), the International Bowel Ultrasound Segmental Activity Score (IBUS-SAS)¹, with other IUS scores specifically developed for UC, in terms of correlation with endoscopic activity.
Patients with UC ≥ 18 years old undergoing partial or full colonoscopy between April 2023 and January 2024 were prospectively included. Endoscopic evaluation of at least the sigmoid colon was mandatory for inclusion, and patients with proctitis (Montreal E1) were excluded. Endoscopic activity was scored with both the Mayo Endoscopic Subscore (MES) and the Ulcerative Colitis Endoscopic Index of Severity (UCEIS), and defined by MES ≥ 1 and UCEIS ≥ 2. Moderate endoscopic activity was determined by a MES = 2 or an UCEIS = 5-6, while severe activity was defined by a MES = 3 or an UCEIS ≥ 7. IUS was performed within 4 weeks of endoscopy. The IBUS-SAS, the Milan Ultrasound Criteria (MUC)², the UC-IUS score³, the US Score from Parente et al.⁴, and the Hata index⁵ were included in the analysis. Applicability of the Civitelli index⁶, an IUS score developed for pediatric patients, was also evaluated. The Spearman’s rank coefficient [rho = ρ] was used to perform correlations, while receiver operating characteristic (ROC) curves were compared with the Hanley & McNeil method.

Results

Collectively, 104 patients were included in the study. The majority of patients (61.5%) had extensive colitis (Montreal E3), with half of them having an active disease at endoscopy (54.8% using MES and 48.1% using UCEIS). IUS examination was performed at a median time of 8 days (IQR 2-15) after endoscopy. All the investigated scores were significantly able to distinguish between the 3 grades of severity of colonic inflammation, using both MES and UCEIS as a reference, with the exception of the Parente’s US Score for the severe endoscopic activity assessed with UCEIS [0 (IQR 0-1) for UCEIS < 7 vs 1 (IQR 0-1) for UCEIS ≥ 7, p=0.09]. The IBUS-SAS showed a strong correlation with endoscopic activity, both with MES (ρ = 0.71, p < 0.01) and UCEIS (ρ = 0.73, p < 0.01) assessments. The Area Under the Curve (AUC) of IBUS-SAS to detect an endoscopic activity of at least moderate severity (MES ≥ 2 and UCEIS ≥ 5) was 0.85 and 0.90, respectively. The optimal cutoff to detect a MES ≥ 2 and UCEIS ≥ 5 was > 11 (sensitivity 75% and specificity 82%) and > 22 (sensitivity 92% and specificity 80%), respectively. Both cut-offs showed progressive increase from mild to severe activity, with IBUS-SAS maintaining a consistently high AUC at different thresholds. Consistent with IBUS-SAS results, all the investigated UC-developed IUS scores correlated with both the MES and the UCEIS (p < 0.01). AUC values and relative comparisons between the AUC are detailed in Table 1.

Table 1. Relative comparisons between the AUC of each score to detect a MES ≥ 2 (A, top-right) and an UCEIS ≥ 5 (B, bottom-left) are reported.
Grey rows and columns: AUC values (with 95%CI).
White cells: p-values obtained via the Hanley and McNeil method (significant p-values are shown in bold).

Conclusion

In this study we provide a successful validation of 6 IUS scores for UC. The IBUS-SAS has an optimal performance in predicting endoscopic activity also in patients with UC, despite having been developed initially for CD.

References

1. Novak KL, Nylund K, Maaser C, et al. Expert Consensus on Optimal Acquisition and Development of the International Bowel Ultrasound Segmental Activity Score [IBUS-SAS]: A Reliability and Inter-rater Variability Study on Intestinal Ultrasonography in Crohn's Disease. J Crohns Colitis 2021;15:609-616
2. Allocca M, Fiorino G, Bonovas S, et al. Accuracy of Humanitas Ultrasound Criteria in Assessing Disease Activity and Severity in Ulcerative Colitis: A Prospective Study. J Crohns Colitis 2018;12:1385-1391
3. Bots S, Nylund K, Löwenberg M, et al. Intestinal Ultrasound to Assess Disease Activity in Ulcerative Colitis: Development of a novel UC-Ultrasound Index. J Crohns Colitis 2021;15:1264-1271
4. Parente F, Molteni M, Marino B, et al. Are colonoscopy and bowel ultrasound useful for assessing response to short-term therapy and predicting disease outcome of moderate-to-severe forms of ulcerative colitis?: a prospective study. Am J Gastroenterol 2010;105:1150-7
5. Kinoshita K, Katsurada T, Nishida M, et al. Usefulness of transabdominal ultrasonography for assessing ulcerative colitis: a prospective, multicenter study. J Gastroenterol 2019;54:521-529
6. Civitelli F, Di Nardo G, Oliva S, et al. Ultrasonography of the colon in pediatric ulcerative colitis: a prospective, blind, comparative study with colonoscopy. J Pediatr 2014;165:78-84.e2

Disclosure

GD reports speaker fees from Alfasigma, Johnson & Johnson, Novartis, Pfizer, Takeda, and has served in advisory board for Celltrion Healthcare and Pfizer. The other authors have no conflict of interests to declare.

Introduction

Colorectal cancer (CRC) screening programmes have been shown effective in reducing CRC incidence and mortality. Risk stratification offers opportunities for further optimisation of screening programmes by better balancing the harms and benefits of screening. To this day, nearly all population screening programmes only differentiate their screening approach by age, resulting in a fixed upper age limit of screening. While further risk stratification based on prior faecal haemoglobin (f-Hb) concentration seems promising, studies are mainly limited to the target population of screening. Risk-stratified screening beyond the upper age limit might however be beneficial as well considering the increasing life expectancy and the benefit-risk ratio of screening widely varying amongst elderly.

Aims & Methods

This study assessed interval colorectal cancer (IC) risk in individuals that have reached the upper age limit of screening (75 years), and whether this risk differs by the f-Hb concentration of the last faecal immunochemical test (FIT). Individuals with a negative FIT (<47 µg Hb/g faeces) in their final CRC screening round were selected in the national screening database and linked to the Dutch cancer registry to check for a CRC diagnosis within 24 months of the negative FIT. IC risk was compared between different risk groups (sex, prior f-Hb concentration and screening round) and tested with a Chi-squared test. Associations between IC and explanatory factors were assessed using survival and Cox proportional hazards analyses. Factors associated with CRC stage were identified using a multivariable logistic regression analysis.

Results

A total of 311,655 individuals with a complete follow-up (24 months) after a negative FIT were included. Within this population, the overall IC risk was 21.6 per 10,000 individuals with a negative FIT. Individuals with detectable f-Hb (>0µg Hb/g faeces) in the final screening round developed IC more often than those without (HR 4.85, 95%CI: 4.18-5.63) (Table 1). Besides, they were also more likely to be diagnosed at an advanced rather than early stage of the disease (OR 1.45, 95%CI: 1.05-2.00). Individuals who had participated in three or four screening rounds had a lower IC risk than those who had participated once (HR 0.75, 95%CI: 0.56-0.99). Screening round was not associated with stage distribution and sex was not associated with IC nor stage distribution.

Table 1; Overview of IC risk, including results of a Cox regression analysis with IC as a dependent variable and sex, screening round and prior f-Hb concentration as independent variables

Conclusion

Our results indicate that a risk-stratified upper age limit in CRC screening based on prior f-Hb concentration may prevent CRC cases and CRC-related morbidity by early detection. While individuals with detectable f-Hb in their final FIT may benefit from additional screening, screening of the elderly is not without risks. Follow-up studies should therefore assess the benefit-risk ratio of a risk-stratified upper age limit and identify the optimal screening scenario.

Introduction

The metaverse consists of interconnected 3D virtual worlds that offer immersive experiences to users by stimulating a sense of presence, primarily through wearable headsets. Extended reality (XR), the core technology of the metaverse, combines virtual reality (VR), augmented reality (AR), and mixed reality (MR) to provide a shared online space where users can interact in both physical and virtual worlds.

Aims & Methods

We developed a holography-guided surgical navigation system based on the metaverse platform to improve spatial awareness in gastrointestinal (GI) and hepatobiliary-pancreatic (HPB) laparoscopic and robotic surgeries and investigated its usefulness.
We performed 40 endoscopic/laparoscopic GI and HPB surgeries using a metaverse-based holography-guided surgical navigation system. Over 20 Asian surgeons used a head-mounted display (HMD) during surgery. Holographic 3D guides of organs, lesions, and procedures were created based on individual patient CT/MRI images, providing a realistic 3D view in real space above the surgical field. Simultaneously, lifelike 3D avatars of surgeons were created, allowing for remote surgical planning and discussions in the metaverse.

Results

In all 40 surgeries, tumor lesions, surrounding organs, and blood vessels were accurately spatially reproduced as holographic images in a sterile space above the patient's abdomen, along with resection lines to guide surgical techniques. The system setup took less than 5 minutes on average, and no postoperative adverse events occurred in any patient. Positioning errors in superimposing the virtual models were within 2mm. Holographic avatars increased the efficiency and effectiveness of reviewing, brainstorming, and sharing virtual content. Holographic guidelines allowed surgeons to share their positions and hand movements, proving useful for hands-on training.

Conclusion

Our holography-guided surgical navigation system with the metaverse platform facilitated holographic telepresence through augmented reality, transforming the operating room into a 3D workspace. By allowing users to connect remotely and interact with lifelike avatars, our system reduced surgeon stress and unlocks new levels of computing beyond spatial limitations, regardless of any devices were used. We are currently evaluating its usefulness in gastroenterology by applying it to navigation guides for hepatic US-guided radiofrequency ablation (RFA) and endoscopic mucosal disection (ESD) of the gastrointestinal tract.

References

• Maki Sugimoto. Cloud XR (Extended Reality: Virtual Reality・Augmented Reality・Mixed Reality) and 5G networks for holographic medical image-guided surgery and telemedicine. Multidisciplinary Computational Anatomy - Principles and Clinical Application of MCA-based Medicine. pp 381-338, 2021. Editor: Hashizume M. Springer, Singapore. 2021. DOI https://doi.org/10.1007/978-981-16-4325-5_52
• Maki Sugimoto. Extended Reality (XR:VR/AR/MR), 3D Printing, Holography, A.I., Radiomics, and Online VR Tele-Medicine for Precision Surgery. Surgery and Operating Room Innovation. p65-70. Editor: Takenoshita S, Yasuhara H. Springer, Singapore. 2020. DOI https://doi.org/10.1007/978-981-15-8979-9_7
• Maki Sugimoto. Augmented Tangibility Surgical Navigation Using Spatial Interactive 3-D Hologram zSpace with OsiriX and Bio-Texture 3-D Organ Modeling. IEEE 2015 International Conference on Computer Application Technologies (CCATS 2015). 189-194, 2015. DOI:10.1109/CCATS.2015.53

Disclosure

Holoeyes Inc.; Board member