Introduction

In the carcinogenic pathway of colorectal cancer, the first concept is the "adenoma-carcinoma sequence" and the second concept is the " serrated pathway ". In these concepts, adenomas and serrated lesions gradually progress to cancer. The third concept is the "de novo pathway," in which cancer develops without adenomas or serrated lesions and is also characterized by high malignancy and rapid progression. We have endoscopically characterized depressed colorectal cancers considered to be of the "de novo pathway" and validated the usefulness of pit pattern and EC classification.

Aims & Methods

A total of 54819 colorectal neoplasms were resected endoscopically or surgically in our institution from April 2001 to December 2024. They were subjects of this study. Advanced cancers were excluded. Of these, 1694 lesions were submucosally invasive (T1) carcinomas, 7330 lesions were classified as high-grade dysplasia and 39977 lesions as low-grade dysplasia. Morphologically, they were divided into 3 types: depressed, flat, and protruded type comprising 1.0 (%), 46.4 (%),and 52.6（%), respectively. Specifically, the distinctive features of depressed type neoplasms concerning their pit pattern and EC classification were examined. EC classification is a classification for an endocytoscopy that can evaluate pathology, such as nuclear atypia and glandular structure, by magnifying stained cells. EC1a is diagnosed as normal mucosa, EC1b is diagnosed as hyperplastic polyps, and if slit-like glandular ducts or spindle-shaped nuclei are present, it is classified as EC2 and diagnosed as an adenoma or intramucosal carcinoma. If irregularly shaped glandular ducts or nuclei with a high N/C ratio are found, it is classified as EC3a, and diagnosed as intramucosal carcinoma or SM lightly invasive carcinoma. If the glandular ducts are indistinct and the nucleus is irregularly shaped and darkly stained, it is classified as EC3b and diagnosed as SM highly invasive carcinoma.

Results

Most of the flat (91.5%) and protruded type (94.9%) lesions showed type IIIL or IV pit pattern, which are common findings in adenomas. On the other hand, most of the depressed type lesions (92.6%) classified as type IIIs, VI or VN pit patterns, are typically seen in carcinomas. As for endocytoscopy, most of flat and protruded type lesions were identified as EC2 corresponding to adenomas. In contrast, relatively high rates of depressed type lesions were categorized as EC3a (40.3%) and EC3b (52.4%), consistent with invasive carcinomas.
The proportion of T1 carcinomas in depressed type lesions was 58.7%, whereas in flat and protruded type lesions it was 2.5% and 2.5%, respectively. Additionally, 12.0% of depressed type lesions less than 5mm in diameter were T1 carcinomas, whereas flat and protruded type lesions were 0.01% and 0%, respectively.

Conclusion

This study revealed that depressed lesions were classified as type IIIs, VI or VN pit patterns on magnifying endoscopy and as type EC3a or EC3b on endocytoscopy. Lesions with these features or pit patterns tend to invade the submucosal layer even if they are small size. Despite their high potential for malignancy, depressed lesions are often ignored. However, it is critical to recognize their features and accurately diagnose lesions based on morphology, pit pattern, and EC classification.

Disclosure

Shin-ei Kudo and Masashi Misawa received speaking honoraria from Olympus Corporation and have an ownership interest of the products of Cybernet Systems. Tetsuo Nemoto received a research grant from Olympus Corporation for other studies. Other authors have nothing to declare.

Clinical Case Summary

A 59-year-old man was admitted with painless jaundice. Laboratory data revealed elevated liver enzymes and hyperbilirubinemia (ALT 95UI/L, AST 54UI/L, ALP 550UI/L, total bilirubin 6mg/dL and direct bilirubin 4.6mg/dL). CT confirmed an unresectable 4cm perihilar infiltrative lesion with extensive portal vein invasion and cavernous transformation. An US-guided biopsy of the lesion followed by percutaneous transhepatic cholangiography were performed, allowing palliative biliary drainage with non-covered metal stents. Nevertheless, biopsy sample histopathology yielded no intersected neoplastic tissue.
Given the strong suspicion of malignancy and the need for histopathology to guide systemic treatment, endoscopic retrograde cholangiopancreatography (ERCP) with cholangioscopy-guided biopsies was proposed. The procedure started by conventional biliary cannulation. Cholangiography revealed the metallic stents in situ crossing the hilum. Biliary endoscopic sphincterotomy was performed and a 3.2mm cholangioscope (EyeMAX™) was successfully introduced. The common bile duct and the hepatic ducts were carefully explored advancing the cholangioscope through the stents into the intrahepatic ducts. Detailed inspection of the biliary mucosa identified areas of pseudopolypoid appearance covering the stent body in the hilar region with marked friability and aberrant vascularization. Cholangioscopy-guided biopsies were laboriously performed through the mesh of the metal stents using a 1mm biopsy forceps (EyeMAX™ biopsy forceps). No displacement or damage to the stents were observed. Histology confirmed a moderately differentiated cholangiocarcinoma, and palliative chemotherapy could be started.
Biliary non-covered metal stents should only be used after a definite histologic diagnosis of cancer is stablished. Despite the potential technical limitations of this unreported approach, targeted biopsies through the mesh of metallic stents seem effective without compromising stent integrity.

References

Cholangioscopy images.
Fluoroscopy images.
Histopathology images.

Clinical Case Summary

Introduction: Aortoesophageal fistula (AEF) is a rare but fatal cause of upper gastrointestinal bleeding. The disease progression is often rapidly if not promptly recognized.
The most common etiologies include thoracic aortic aneurysm (TAA) and prior aortic surgery. Early diagnosis remain challenge due to nonspecific symptoms. This case series highlights endoscopic features of AEF and the critical role of endoscopists in early detection.
Case present: We report three elderly patients (aged 76–82) who presented to the emergency department with massive hematemesis. One had a history of type B aortic dissection post thoracic endovascular aortic repair (TEVAR) ; the others had no known thoracic disease. None reported mid-thoracic pain. Laboratory data showed hemoglobin 5.1 to 6.2 g/dL without coagulopathy. Esophagogastroscopy (EGD) was performed within 1 hour in two patients, and at 9 hours in the third. EGD showed consistent findings in three cases: a subepithelial bulging mass with central blood clot adherent to the left quadrant (6–9 o’clock) of the mid-esophagus. CT confirmed AEF secondary to ruptured TAA in two patients. Unfortunately, one patient collapsed suddenly in the ED; the others underwent emergent surgery but died within 1 and 21 days postoperatively.(esophagectomy +/- TEVAR).
Discussion: Chiari’s triad (mid-thoracic pain, sentinel bleeding, fatal hematemesis) is classically associated with AEF but was absent in half patients. In our report, EGD can be a most timely and specific modality to early diagnosis of AEF, especially in patients without clear prior aortic disease. The typical endoscopic feature : bulging submucosal mass with central blood adherent clot may serve as a diagnostic clue. And the “hot-zone” of the AEF in EGD was located at left quadrant (six to nine o’clock) of mid esophagus .
Conclusion: Early recognition of typical characteristic and “hot zone” of AEF on EGD may improve timely diagnosis of AEF and guide life-saving interventions.

References

1. Bergqvist D. Arterioenteric fistula. Review of a vascular emergency. Acta Chir Scand 1987;153:81–6.
2. Hollander JE, Quick G. Aortoesophageal fistula: a comprehensive review of the liter- ature. Am J Med 1991;91:279–87.
3. Mortensen A, Hansen NF, Schiodt OM. Fatal aortoesophageal fistula caused by but- ton battery ingestion in a 1-year-old child. Am J Emerg Med 2010;28(984):e5-6.
4. Takeno S, Ishii H, Nanashima A, Nakamura K. Aortoesophageal fistula: review of trends in the last decade. Surg Today. 2020 Dec;50(12):1551-1559.

Introduction

This study aims to assess the impact of antithrombotic therapy on endoscopic findings in patients hospitalized for upper gastrointestinal bleeding.

Aims & Methods

We carried out a prospective, single-center cross-sectional study including 332 patients between June 2020 and February 2025. Patients were classified as antithrombotic (AT) users if they were receiving antiplatelet agents (such as low-dose aspirin or thienopyridines) and/or anticoagulants (including vitamin K antagonists, direct oral anticoagulants, or heparin).

Results

The mean age of the study population was 59 ± 16.7 years, with a marked male predominance (77.1%). Among them, 63 patients (19%) were receiving antithrombotic (AT) therapy—41 on antiplatelet agents and 39 on anticoagulants. Patients in the AT group were significantly older (68 vs. 57 years; p < 0.001) and had a higher burden of comorbidities (75.8% vs. 16.7%; p < 0.001). However, there were no significant differences between the AT and non-AT groups regarding the presence of active bleeding at endoscopy (12.7% vs. 16.8%; p = 0.425) or the need for endoscopic hemostasis (7.9% vs. 16%; p = 0.1).
In multivariate analysis, after adjustment for age, sex, comorbidities, active bleeding, and AT use, only the presence of active bleeding was independently associated with the need for endoscopic hemostasis. Specifically, active bleeding at endoscopy increased the odds of requiring hemostasis by 26-fold (OR: 26, 95% CI: 12.9–62.15; p < 0.001), whereas AT therapy was not an independent predictor (OR: 0.386, 95% CI: 0.105–1.42; p = 0.154).

Conclusion

In older patients receiving antithrombotic therapy and admitted for upper gastrointestinal bleeding, the risk of active bleeding during endoscopy and the need for endoscopic hemostasis do not appear to be increased.

Introduction

Gastrointestinal (GI) endoscopy requires not only technical skills but also strong non-technical abilities like communication, teamwork, and decision-making. Traditional training is often individualized, with little focus on interdisciplinary collaboration. Role Swapping (RS) — where physicians and nurses exchange tasks during simulated procedures — may enhance teamwork and mutual understanding.

Aims & Methods

A prospective pilot study was conducted involving 22 participants (10 endoscopists, 12 nurses) using in-silico colonoscopy simulators. The training included a pre-simulation skills assessment, theoretical onsite classes, randomized role-swapping simulation sessions, and a post-simulation evaluation after two weeks. Technical skills, non-technical skills (assessed via NOTSS and SPLINTS frameworks), and satisfaction were evaluated using validated questionnaires. Wilcoxon tests compared pre- and post-training scores.

Results

RS in simulated GI endoscopy training significantly enhanced both technical and non-technical competencies among participants. Post-training assessments using validated tools showed improvements across all evaluated domains. Situational awareness, decision-making, communication, teamwork, and leadership skills all exhibited statistically significant gains. Participants improved their ability to gather information (p=0.02), understand data (p=0.008), and anticipate future scenarios (p=0.002). Decision-making skills were notably enhanced, with better option consideration (p<0.001), more transparent communication of decisions (p=0.001), and greater adaptability to dynamic conditions (p<0.001). Communication improvements included more effective information exchange (p=0.007), better shared understanding (p=0.035), and increased team coordination (p=0.001). Leadership skills were also significantly strengthened, particularly in setting standards (p=0.002) and supporting teammates (p=0.012). Regarding technical skills, endoscopists reported substantial confidence improvements in tasks traditionally performed by nurses. Significant progress was observed in preparing endoscopic equipment (p=0.016), medication dilution (p=0.016), patient discharge procedures (p=0.014), instrument arrangement during interventional colonoscopies (p=0.026), and setup of patient monitoring systems (p=0.041). Confidence also increased in tasks initially rated as low-confidence, such as proper waste disposal after GI procedures (p=0.01). Nurses, conversely, enhanced their technical capabilities related to GI endoscopy performance. They showed greater proficiency in advancing the colonoscope (p=0.004), reducing loops (p=0.007), navigating angled turns (p=0.007), executing ancillary maneuvers (p=0.038), and conducting thorough mucosal inspections during withdrawal (p=0.036). Improvements were also seen in colonoscope insertion (p=0.026), understanding of colonoscopy quality indicators (p=0.011), and lesion identification (p=0.046). Participant feedback revealed high satisfaction with the RS training experience. Participants appreciated the opportunity to engage in cross-disciplinary tasks, reporting that the simulation increased their mutual respect, role awareness, and confidence in collaborative practices.

Conclusion

Role swapping during simulated GI endoscopy training enhanced both technical and non-technical skills and fostered better collaboration between nurses and physicians. This innovative educational approach shows potential to improve clinical practice quality and patient safety.

References

1. Hedges AR, Johnson HJ, Kobulinsky LR, et al. Effects of Cross-Training on Medical Teams’ Teamwork and Collaboration: Use of Simulation. Pharmacy (Basel) 2019; 7: 13.
2. de Laurentis C, Pirillo D, Di Cristofori A, et al. Boosting teamwork between scrub nurses and neurosurgeons: exploring the value of a role-played hands-on, cadaver-free simulation and systematic review of the literature. Front Surg 2024; 11: 1386887.

Introduction

Various complications can occur in the course of digestive tuberculosis (DTB), such as intestinal obstruction, perforation, fistula formation, or gastrointestinal bleeding, all of which can significantly compromise patient prognosis.

Aims & Methods

The aim of our study was to identify factors associated with the development of these complications.
We conducted a retrospective analytical study including patients diagnosed with DTB over an eight-year period (2017–2024). Clinical, biological, and complication-related data were collected and analyzed.

Results

Ninety-six patients were included, with a mean age of 50.7 years (range: 19–90 years). The sex ratio (M/F) was 2. The diagnosis was confirmed primarily through histological analysis of peritoneal biopsies obtained via laparoscopy (52.1%), revealing epithelioid and multinucleated giant cell granulomas with caseating necrosis in 80% of cases. Additional diagnostic methods included the detection of Mycobacterium tuberculosis bacilli in ascitic fluid by direct microscopy (n=2), and molecular testing on colonic biopsies (n=2) or ascitic fluid (n=4).
Clinical outcomes were favorable in 87.5% of cases. Complications were observed in four patients (4.1%), including intestinal perforation (n=2), bowel obstruction (n=6), and death (n=2). One patient experienced early recurrence, and two others had persistent radiological findings despite adequate treatment (n=4).
Univariate analysis showed that severe malnutrition was significantly associated with the occurrence of complications (p=0.001).

Conclusion

Complications were observed in 4.2% of patients with DTB. Severe malnutrition was significantly linked to the development of these adverse outcomes, highlighting the critical importance of early and adequate nutritional support in the management of digestive tuberculosis.

Introduction

Colorectal cancer (CRC) is the second most common cancer and the third leading cause of cancer-related deaths in Brazil. High-income countries with organized screening programs have achieved significant reductions in CRC mortality in the last decades through early detection, polypectomy, and improved therapeutic interventions. Meanwhile, several low- and middle-income nations continue to experience rising incidence and persistently high mortality rates. Understanding CRC mortality patterns across different age groups and sexes is essential to guide public health policies and optimize resource allocation for prevention, early detection, and treatment strategies.

Aims & Methods

This study aimed to analyze CRC mortality trends in Brazil from 2012 to 2021. We conducted a descriptive analysis of CRC-related deaths (ICD-10 codes C18, C19, and C20) using data from the Mortality Information System of the Unified Health System (DATASUS). The crude annual mortality rate (deaths per 100,000 inhabitants) was calculated by dividing the number of deaths by the estimated population provided by the Brazilian Institute of Geography and Statistics (IBGE). We also analyzed annual mortality rates by age range and sex and calculated the average annual percent change (AAPC) in mortality rates to assess trends over time.

Results

A total of 175,159 CRC-related deaths were recorded in Brazil between 2012 and 2021, with 86,330 occurring in men and 88,829 in women. Among men, 27.4% of deaths occurred before age 60, 53.8% between ages 60 and 79, and 18.8% at age 80 or older, while among women, these proportions were 27.4%, 47.1%, and 25.5%, respectively. During this period, CRC mortality rates increased in both sexes, rising from 7.06 to 9.73 deaths per 100,000 men and from 7.29 to 9.16 deaths per 100,000 women. Consequently, the male-to-female mortality ratio grew from 0.97 in 2012 to 1.06 in 2021, leading to a slight predominance of male gender at the end of the assessed period. The AAPC in mortality was higher in men than in women across all age groups, except for those aged 40–59 years (Table 1). Among younger individuals, those aged 30–39 years had a low absolute mortality rate (<0.4 deaths per 100,000 inhabitants) but showed the highest AAPC (3.5% per year in men and 2.8% per year in women). Among individuals within the recommended CRC screening age range, the highest AAPC was observed in those aged 60–69 years (2.1% per year in men and 1.7% per year in women).

Conclusion

The concerning rise in CRC mortality in Brazil underscores the need for enhanced public health strategies, including improved access to screening and better healthcare resources. Additionally, the greater increase in mortality rates from early-onset colorectal cancer, particularly between ages 20 and 39, warrants attention, with a focus on identifying high-risk individuals and addressing modifiable risk factors in the population.

Table 1 –Average annual percent change in colorectal cancer mortality rate by sex and age range.