Training in optical diagnosis in community hospitals is associated with improved recognition and treatment of T1 CRC: a prospective multicenter intervention study (OPTICAL II).

BACKGROUND AND STUDY AIMS: Recognition of T1 colorectal cancer (CRC) is difficult, with sensitivities of 35-60% in Western countries. We evaluated the real-life effects of the implementation of the OPTICAL model, a recently developed structured and validated prediction model, in Dutch community hospitals. PATIENTS AND METHODS: In this prospective multicenter study, 383 endoscopists from 40 hospitals were invited to follow an e-learning on the OPTICAL-model, to increase sensitivity for detecting T1CRC in non-pedunculated polyps. Next, real-life recognition of T1CRC was evaluated in 25 hospitals. Endoscopic and pathologic reports of T1CRCs detected during the next year were collected retrospectively while endoscopists were unaware of this evaluation. Sensitivity for recognition of T1CRC, R0 resection rate, and treatment modality were compared for trained vs. untrained endoscopists and for recognised vs. unrecognised T1CRCs. RESULTS: Within 1 year after the e-learning 251 endoscopists detected 528 non-pedunculated T1CRCs, 118 (47%) of the endoscopist were trained. T1CRCs had a median size of 20mm and were mainly located in the distal colorectum (66%). Trained endoscopists recognised T1CRCs more frequently than untrained endoscopists (sensitivity 74% vs. 62%; mixed model analysis OR 2.90; 95%CI 1.54-5.45. A higher rate of R0 resection was seen for T1CRCs detected by trained endoscopists (69% vs. 56%, OR 1.73; 95%CI 1.03-2.91). CONCLUSION: Training in optical recognition of T1CRCs in community hospitals was associated with an increase in sensitivity for T1CRCs. Recognition led to a higher rate of en bloc local excision, resulting in higher R0-resection rates. This may be an important step towards more organ-preserving strategies.

Standardised training for endoscopic mucosal resection of large non-pedunculated colorectal polyps to reduce recurrence (*STAR-LNPCP study): a multicentre cluster randomised trial.

OBJECTIVE: Endoscopic mucosal resection (EMR) is the preferred treatment for non-invasive large (≥20 mm) non-pedunculated colorectal polyps (LNPCPs) but is associated with an early recurrence rate of up to 30%. We evaluated whether standardised EMR training could reduce recurrence rates in Dutch community hospitals. DESIGN: In this multicentre cluster randomised trial, 59 endoscopists from 30 hospitals were randomly assigned to the intervention group (e-learning and 2-day training including hands-on session) or control group. From April 2019 to August 2021, all consecutive EMR-treated LNPCPs were included. Primary endpoint was recurrence rate after 6 months. RESULTS: A total of 1412 LNPCPs were included; 699 in the intervention group and 713 in the control group (median size 30 mm vs 30 mm, 45% vs 52% size, morphology, site and access (SMSA) score IV, 64% vs 64% proximal location). Recurrence rates were lower in the intervention group compared with controls (13% vs 25%, OR 0.43; 95% CI 0.23 to 0.78; p=0.005) with similar complication rates (8% vs 9%, OR 0.93; 95% CI 0.64 to 1.36; p=0.720). Recurrences were more often unifocal in the intervention group (92% vs 76%; p=0.006). In sensitivity analysis, the benefit of the intervention on recurrence rate was only observed in the 20-40 mm LNPCPs (5% vs 20% in 20-29 mm, p=0.001; 10% vs 21% in 30-39 mm, p=0.013) but less evident in ≥40 mm LNPCPs (24% vs 31%; p=0.151). In a post hoc analysis, the training effect was maintained in the study group, while in the control group the recurrence rate remained high. CONCLUSION: A compact standardised EMR training for LNPCPs significantly reduced recurrences in community hospitals. This strongly argues for a national dedicated training programme for endoscopists performing EMR of ≥20 mm LNPCPs. Interestingly, in sensitivity analysis, this benefit was limited for LNPCPs ≥40 mm. TRIAL REGISTRATION NUMBER: NTR7477.

Exposure to Thioguanine During 117 Pregnancies in Women With Inflammatory Bowel Disease.

BACKGROUND: Safety of thioguanine in pregnant patients with inflammatory bowel disease [IBD] is sparsely recorded. This study was aimed to document the safety of thioguanine during pregnancy and birth. METHODS: In this multicentre case series, IBD patients treated with thioguanine during pregnancy were included. Data regarding disease and medication history, pregnancy course, obstetric complications, and neonatal outcomes were collected. RESULTS: Data on 117 thioguanine-exposed pregnancies in 99 women were collected. Most [78%] had Crohn's disease and the mean age at delivery was 31 years. In 18 pregnancies [15%], IBD flared. Obstetric and infectious complications were seen in 15% [n = 17] and 7% [n = 8] of pregnancies, respectively. Ten pregnancies [8.5%] resulted in a first trimester miscarriage, one in a stillbirth at 22 weeks of gestational age and one in an induced abortion due to trisomy 21. In total, 109 neonates were born from 101 singleton pregnancies and four twin pregnancies. One child was born with a congenital abnormality [cleft palate]. In the singleton pregnancies, 10 children were born prematurely and 10 were born small for gestational age. Screening for myelosuppresion was performed in 16 neonates [14.7%]; two had anaemia in umbilical cord blood. All outcomes were comparable to either the general Dutch population or to data from three Dutch cohort studies on the use of conventional thiopurines in pregnant IBD patients. CONCLUSION: In this large case series, the use of thioguanine during pregnancy is not associated in excess with adverse maternal or neonatal outcomes.

Superior Effectiveness of Tofacitinib Compared to Vedolizumab in Anti-TNF-experienced Ulcerative Colitis Patients: A Nationwide Dutch Registry Study.

BACKGROUND & AIMS: Clinicians face difficulty in when and in what order to position biologics and Janus kinase inhibitors in patients with anti-tumor necrosis factor-alpha (TNF) refractory ulcerative colitis (UC). We aimed to compare the effectiveness and safety of vedolizumab and tofacitinib in anti-TNF-exposed patients with UC in our prospective nationwide Initiative on Crohn and Colitis Registry. METHODS: Patients with UC who failed anti-TNF treatment and initiated vedolizumab or tofacitinib treatment were identified in the Initiative on Crohn and Colitis Registry in the Netherlands. We selected patients with both clinical as well as biochemical or endoscopic disease activity at initiation of therapy. Patients previously treated with vedolizumab or tofacitinib were excluded. Corticosteroid-free clinical remission (Simple Clinical Colitis Activity Index ≤2), biochemical remission (C-reactive protein ≤5 mg/L or fecal calprotectin ≤250 µg/g), and safety outcomes were compared after 52 weeks of treatment. Inverse propensity score-weighted comparison was used to adjust for confounding and selection bias. RESULTS: Overall, 83 vedolizumab- and 65 tofacitinib-treated patients were included. Propensity score-weighted analysis showed that tofacitinib-treated patients were more likely to achieve corticosteroid-free clinical remission and biochemical remission at weeks 12, 24, and 52 compared with vedolizumab-treated patients (odds ratio [OR], 6.33; 95% confidence interval [CI], 3.81-10.50; P < .01; OR, 3.02; 95% CI, 1.89-4.84; P < .01; and OR, 1.86; 95% CI, 1.15-2.99; P = .01; and OR, 3.27; 95% CI, 1.96-5.45; P < .01; OR, 1.87; 95% CI, 1.14-3.07; P = .01; and OR, 1.81; 95% CI, 1.06-3.09; P = .03, respectively). There was no difference in infection rate or severe adverse events. CONCLUSIONS: Tofacitinib was associated with superior effectiveness outcomes compared with vedolizumab in anti-TNF-experienced patients with UC along with comparable safety outcomes.

Inability to walk: a rare presentation of Crohn's disease.

A wide variety of extraintestinal manifestations of inflammatory bowel disease (IBD) have been described, with joint or dermatological complaints as most prevalent. However, also neurological manifestations can occur, which are rarely recognised and therefore under-reported. We present an very unusual case of a young man who presented with the inability to walk, as a first presentations of IBD.

[Dabigatran-induced oesophagitis]. / Dabigatran-geïnduceerde oesofagitis.

BACKGROUND: Dabigatran is a direct oral anticoagulant which is used as an alternative to the traditional vitamin K antagonists. Dabigatran can have various gastro-intestinal side effects. In this article we describe the case of a patient with dabigatran-induced oesophagitis and we present an overview of current literature. CASE DESCRIPTION: An 87-year-old woman presented at the accident and emergency department with a 3-week history of nausea and melena. The patient had atrial fibrillation and hypertension with cardiac dilation. Phenprocoumon had been replaced with dabigatran 3 weeks previously. Gastroscopy showed elongated ulceration and exfoliation in the distal section of the oesophagus, consistent with dabigatran-induced oesophagitis. The patient was treated with an intravenous proton-pump inhibitor and the symptoms disappeared. The oesophageal mucosa was completely healed 8 weeks later. CONCLUSION: It is important to recognize the symptoms and endoscopic picture of dabigatran-induced oesophagitis as dabigatran is increasingly being prescribed. In order to prevent dabigatran-induced oesophagitis it is essential to give the patient thorough instructions about how to take this medication.

[Abdominal pain caused by mobile caecum with strangulation]. / Buikpijn door mobiel caecum met strangulatie.

An 84-year-old woman was admitted to the emergency department of the St. Elisabeth Hospital in Curaçao for acute diffuse abdominal pain. Her medical history revealed an 'irritable bowel syndrome' with symptoms of chronic progressive abdominal pain. Plain abdominal radiography and computed tomography showed a substantially dilated bowel with torsion of the organ structures and suspected strangulation of the colon. Perioperative examination revealed a distended mobile caecum and right hemicolon. There was also strangulation and herniation of both structures through the foramen of Winslow around the hepatoduodenal ligament, protruding through the minor omentum. After destrangulation and closure of the herniation a caecopexy with an additional appendectomy was performed. Mobile caecum is defined as a failure of the right colon to fuse to the posterior parietal peritoneum. The symptoms of chronic abdominal pain may have been the result of the pre-existing mobile caecum.