Non melanoma skin cancer (NMSC) is amongst the most common cancers worldwide and the incidence of both melanoma and NMSC is still rising. This is not only due to people reaching an older age, but also to the increasing amount of people receiving immunosuppressive medication. While immunosuppression in organ transplant patients serves as the most well-known model for these iatrogenic induced skin cancers, alternative forms of immunomodulating therapies, such as the biologicals, also caught attention because of their potential to disrupt skin cancer immunosurveillance.  Data on biologicals, with anti-TNFα most studied, are more controversial, however, and diverge according to the  inflammatory disease (Inflammatory Bowel Disease (IBD), psoriasis or rheumatoid arthritis) for which they are given.

1. To learn about the epidemiology of Small Bowel Adenocarcinoma. 
2. To understand the absolute risk and relative risk linked to it.  
3. To review practical management of Dysplasia/ SBA

Educational objectives
To discuss the evidence for somatic mutation in the IBD affected colonic epithelium
To consider mechanisms mutagenesis
To discuss evidence for selection pressures on mutations and their implications for cancer risk and inflammation

1. To identify the areas where standardisation of IBD pathology reporting is achievable and the areas requiring improvement. 
2. To recognise the importance of a multidiscipinary approach and good communication.
3. To consider the development of a consistent approach to the assessment and description of IBD histology.
4. To be aware of the diversity of approaches to the assessment of histological acitvity. 
4. To explore the ideal ways in which to construct the summary and conclusion of an IBD pathology report.
5. To be aware of the existence and value of guidelines and datasets in pathology generally and in IBD pathology in particular.  

Four randomized controlled trials studying faecal microbiota transplantation (FMT) in active UC patients showed variable success rates. The efficacy of FMT appears to be influenced by various factors including donor- and procedure-specific characteristics. We hypothesized that the outcome of FMT in patients with active UC could be improved by donor preselection on microbiota level, by using a strict anaerobic approach, and by repeated FMT administration.

The RESTORE-UC trial (NCT03110289) was a national, multi-centric double-blind, sham-controlled randomized trial. Active UC patients (Total Mayo score 4-10 with endoscopic sub-score ≥2) were randomly allocated (1:1) to receive 4 anaerobic-prepared superdonor (S) FMT or autologous (A) FMT (Figure 1) by permutated blocks (2 and 4) and stratified for weight, concomitant steroid use, and therapy refractoriness.
S-FMTs were selected after a rigorous screening excluding samples with Bacteroides2 enterotype, high abundances of Fusobacterium, Escherichia coli and Veillonella and the lowest microbial loads (Q1).
A futility analysis after 66% (n=72) of inclusions was planned per protocol including a modified intention-to-treat (mITT) analysis using non-responder imputation (NRI) for patients receiving at least one FMT. The primary endpoint was steroid-free clinical remission (Total Mayo ≤ 2, with no sub-score >1) at week 8.

Between March 2017-2021, 72 patients signed the ICF and 66 were randomly allocated to S-FMT (n=30) or A-FMT (n=36) and received at least one FMT. In the S-FMT and the A-FMT resp. 4 and 5 patients terminated the trial early due to worsening of colitis (4 in both arms) or FMT enema intolerance (1 A-FMT). They were included in the mITT analysis using NRI (Fig. 2). Both study arms were matched for baseline characteristics (Table 1), yet a trend (p= 0.066) towards higher concomitant biological use in the S-FMT arm was observed.
After 66% of intended inclusions, the primary endpoint was reached in 3/30 (10%) S-FMT and 5/31 (13.9%) patients randomized to A-FMT (p=0.72).
As the predefined minimum difference between both treatment arms was not attained, the study was stopped due to futility. The full set of endpoints are summarized in Table 2.Of note, no patients on concomitant biologicals reached the primary endpoint.
There were 2 serious adverse events in the A-FMT arm: dysuria requiring hospitalization and worsening of UC requiring colectomy.

In this double-blind sham-controlled trial comparing repeated administrations of anaerobic-prepared S-FMT with A-FMT in patients with active UC, no significant difference in steroid-free remission rates at week 8 were observed. The FMT procedure was generally well tolerated, and no new safety signals were observed.

Optimization and standardization of imaging reporting is currently an unmet need and would facilitate the comparison between different reports and communication between the different specialties involved in IBD. The current presentation summarizes results of a consensus guideline that has been developed by members of ECCO, IBUS and ESGAR. The consensus group identified standardized parameters and suggests how to report and how to characterize findings of cross-sectional imaging that encompasses MRI, CT, IUS, endoanal ultrasonography [EAUS] and transperineal ultrasonography [PUS] in IBD. These methods are used for diagnosis, assessment of disease activity and severity, and to detect complications and monitor disease course. Mural and extramural disease manifestations beyond the reach of the endoscope can be visualized and determined by cross sectional imaging.

The core elements of the presentation will describe the imaging parameters of assessment of disease activity and severity as well as intra- and extramural complications of IBD in a standardized manner. The presentation will suggest vital data for each reporting type, and proposes possible strategies to optimize and standardize reporting quality of cross-sectional imaging in IBD. Similarities and differences in reporting between MRI/CT and IUS will be identified and addressed. Practical examples will be provided on how to standardize reporting of individual cases in daily clinical practice.

Educational objectives:
•Synthesis and structure
•Mechanism of action
•Effects on inflammatory and immune processes
•Pharmacology  and formulations
•Efficacy of steroids as anti-inflammatory agents in inflammatory bowel diseases (IBD)
•Safety and complications

The isoperistaltic side-to side strictureplasty over the valve provdes a means to avoid ileocaecal resection in patients with stricturing terminal ieal disease.  Indications are a long segment of diseased terminal ileum (> 35 cm) or multiple adjacent strictures over a long length of bowel.
The technque has shown teo be safe with acceptable septic complications.  To imrove long-term outcome a broad inlet to the strictureplasty should be created (Sasaka modification).  About 1 in 4 patients will develop a deep remission and do not need further medical treatment.  The stricutreplasty can be monitored with flexible endoscopy.  A proximal to distal healing has been observed and a remoddeling of the bowel wall occurs (transsectional imaging). On the long-term efficacy equals the outcome of resection especially in an era of thight disease follow-up.  A surgical resection rate of 16% at 5 yrs has been noted.  The need to resect the stricutreplasty was extremely limied.
Despite those findings the complexity of the procedure hampers widespread implementation.

Data on the outcomes of surgery due to IBD in pregnant patients is scarce, and primarily dates back more than 3 decades ago. Primary aim: to evaluate the evolution of pregnancies and offspring after surgery due to IBD. Secondary aims: to describe the indications for surgery, the surgical techniques used, and the frequency of caesarean section concomitant to surgery for IBD

SCAR is a retrospective, multicenter study approved by ECCO COllaborative Network For Exceptionally Rare Case Reports (CONFER). Patients operated on due to IBD during pregnancy after 1998 (first biologic agent approved) were included. Data on patients’ demographics, IBD characteristics, medical treatments, IBD activity, pregnancy outcomes, surgery, delivery, foetal and maternal outcomes, were recorded

44 IBD patients were included (figure 1),

all singleton pregnancies. Seven patients (16%) were diagnosed with IBD during pregnancy, 75% had Crohn’s disease (51% fistulizing behavior), and 23% had ulcerative colitis. 34% had previously undergone surgery due to IBD. Several complementary examinations were performed during pregnancy without complications (figure 2)
Patients were being administered the following medications: corticosteroids (61%), biologicals (57%), thiopurines (23%) with 20% being on biologics and thiopurines. 93% of surgeries were performed in University hospitals, (2^nd Trimester: 55%; 3^rd trimester: 27%) with 77% of them being urgent surgeries (figure 3)
One patient had hemoperitoneum during surgery, and 27% had postsurgical complications. No woman died. 62.5% of deliveries were induced (figure 4),
70% of them by C-section, with 51% of mothers having a prolonged hospitalization. There were 40 newborns alive and 4 miscarriages/stillbirths (1 in the 1^st, 2 in the 2^nd, and 1 in the 3^rd trimester): 2 occurred during surgery and 2 occurred 2 weeks after surgery. 14% of the surgeries during the 2^nd trimester and 64% of those in the 3^rd trimester ended up with a simultaneous C-section or delivery.  Of the 40 newborns alive, there were 9 healthy (24%), 61% premature, and 47% with low birth weight. A total of 42% of newborns needed hospitalization (25% in the intensive care unit, mainly due to respiratory distress)

The need for surgery for IBD during pregnancy remains an extremely serious situation. Maternal and foetal mortality are lower than previously described, most likely due to better supporting care. However, even in the current years, 30% of the mothers and 80% of newborns have complications, and 25% of the offspring need admission to the intensive care unit. Therefore, surgical management should be performed by a multidisciplinary team, involving gastroenterologists, colorectal surgeons, obstetricians and neonatal specialists.

1. To define the appropriate timing between medical and surgical management of IBD
2. To review medical and surgical treatment indications of the complications of IBD  
3. To learn how to decide in multidisciplinary team between the two modalities of treatment 

This presentation will focus on how to identify risks for surgical complications in surgery for inflammatory bowel disease, as well as how to decrease the risk prior to surgery. There will also be a discussion on how to act when surgical complications have developed, as this risk is increased compared to colorectal surgery in general.

Educational objectives:
1. To review when to perform surgical resection in CD, as illustrated with a patient journey with limited L1 Crohn's disease
2. To get an insight into the surgical procedure via video presentation
3. To summarize literature on risk-stratification, the importance of proactive monitoring and individual treatments for postoperative recurrence

1. to understand when and why surgery is indicated in selected patients with UC

2. to review the different surgical options in patient operated for ulcerative colitis

3. to precise the consequences  for the patient in terme of function, quality of life and follow up, after surgery for UC, according to the operation performed

4. to have an overwiew of the best way to follow a patient after ileal pouch-anal anastomosis for ulcerative colitis

5/ to review the possible problems occurring during follow up up of patients after ileal pouch-anal anastomosis and the treatment for each problem

Discussion about incidence of colorectal cancer, small bowel cancer, and anal cancer in IBD with a focus on surgical strategies

IBD and cancer: surgical strategy in UC

Educational objectives:
- To emphasise that cancer risk is depending on patient and disease characteristics, and varies with duration of disease
- To review the incidence of CRC rate in colectomy specimens over the last decades
- Give an overview of surgical approaches in case of UC malignancy and discuss ongoing controversies (proctocolectomy vs segmental resection/ pouch or not/ mucosectomy/  impact of (neo)-adjuvant therapy)

Educational objectives:

1. To understand the concept of tailored medical therapy in ulcerative colitis 'the right therapy to the right patient at the right time' on the basis of an individual patient’s biology and possible prognostic factors

Treatment algorithms will be presented for different disease presentations of ulcerative colitis. 
Therapeutic drug monitoring will be discussed and the future options of tailored medicine will be discussed.

Robust and sensitive therapeutic targets are key in effective management of Inflammatory Bowel Disease¹. Mesenteric hyperaemia is a recognized sign of active disease and in cross-sectional image is described as the comb sign. Although it is subjectively described, no automated quantitative MRI-based measures have been developed.

We aim to develop an automated methodology using contrast-less time of flight (TOF) Magnetic resonance angiography (MRA).

A MATLAB algorithm was developed to track the vessels on a 3D maximum intensity projection of a TOF MRA data set and calculate an arborization Index which is the number of branching points in the intrabdominal vessels (figure 1). 2D TOF scans were acquired in the transverse plane between the top of the hip joint and L4 vertebra using a 3T Ingenia Wide bore scanner (Philips, The Netherlands). The primary outcome was a comparison of the arborization index between Crohn’s disease (CD) and healthy volunteers (HV) groups. A planned sub-analysis was undertaken across CD and HV matched for BMI to investigate the effect of visceral fat on the arborization index. Repeated measures were undertaken to evaluate the variability of the quantification method. No contrast agents were used for the TOF MRA scans. Biological variations within each group and test-retest repeatability were assessed using the coefficient of variation (CV). Statistical analysis with unpaired, two-tailed t-tests were conducted and differences were considered significant when the p-value ≤0.05. All absolute values are presented as mean ±standard deviation (SD).

In this prospective pilot study, 7 CD patients (C-Reactive Protein=5.2±6.1 mg/L, Faecal Calprotectin 611±981μg/g, BMI=23±3 kg/m²) and 15 HVs (BMI=29±7 kg/m²) were recruited. Patients showed a significantly higher arborization index when compared to HVs (mean arborization in HV=94±21 and CD=139±26; p-value=0.002). The difference in arborization index persisted in a sub-analysis of 7 HVs (BMI=24±2 kg/m²) and 7 CD patients (mean arborization in matched HVs=101±22 vs mean index in CD=139±26; p=0.01) (Figure 2). The CV was 23% for HVs and 18% for CD indicating biological variation. Test-retest variability calculated from multiple TOF scans of the same subjects gave a mean CV of 6±5% for both groups combined.

Our preliminary data suggest that the arborization index may be a useful measure of hypervascularity and hence intestinal inflammation in Inflammatory Bowel Disease. Further validation to standard disease activity measures is needed across larger cohorts to better investigate the utility of this potential biomarker as a non-invasive measure of disease activity and its reversibility to IBD therapies.


1.Turner,D.,et al.Gastro.2021;160(5):1570-1583.

To clarify the risk of lymphoma in patients with inflammatory bowel diseases (IBD) exposed to anti-tumor necrosis factor (anti-TNF) and/or thiopurines we aimed to evaluate the Israeli IBD population.

A nested case-control study on the epidemiology cohort of the Israeli IBD Research Nucleus (epi-IIRN) including all 4 Health Maintenance Organizations in Israel linked to the Israeli Cancer Registry. Patients diagnosed since 1.1.2005 until 31.12.2015 (42,954 patients) were included and followed until 31.12.2017. Each lymphoma case was matched to 30 non-lymphoma IBD patients by age, gender, IBD subtype, and date of earliest evidence of IBD in the database. Patients with other risk factors for lymphoma, or lymphoma diagnosis prior to IBD diagnosis were excluded (figure 1). Conditional logistic regression was used to compute the association of drug exposure (anti-TNF, thiopurines and combination) with diagnosis of lymphoma. Patients without exposure to anti-TNF and/or thiopurines in each group served as reference within each group. Additionally, sub-group analyses by gender, age group at inclusion (≤48, 49-64, ≥65), time from last drug exposure (≤90 days, 91-365 days, >365 days) were done.

The final nested cohort included 5556 IBD patients (185 lymphoma cases matched to 5,371 without lymphoma). Mean follow-up (F/U): 5.5±3.5 years, 50% with Crohn’s disease, mean age at database entry 52.6±17.80 years. Anti-TNF-only exposure was documented in 4.3% (8/185) of lymphoma cases vs. 2.6% (145/5,371) of controls OR 1.97, CI 0.93-4.16, p=0.07; in males the ORs were 2.84 (CI 1.17-6.92 p=0.04) and increased to OR 3.48 (CI 1.55-7.88, p=0.002) for males <48 years and OR 2.87 (CI 1.53-5.37, p=0.001) for patients with last exposure ≤90 days (figure 2). Exposure to combination anti-TNF+thiopurines occurred in 8.6% (16/185) of lymphoma cases vs. 5.3% (282/5,371) of controls OR 2.09 (CI 1.17-3.73, p=0.013). Males on anti-TNF-thiopurine combination had OR of 3.42 (CI 1.37-8.52, p=0.003) and in sequential (non-overlapping exposure to both thiopurines and anti-TNFs during F/U) combination an OR of 2.74 (CI 1.02-7.35 p=0.02). Thiopurine-only exposure occurred in 15.1% (28/185) of lymphoma cases vs. 13.5% (726/5,371) of controls, OR 1.32 (CI 0.86-2.03, p=0.20). Males on thiopurines had an OR of 1.75 (CI 1.02-2.99, p=0.05). The risk increased further in males <48 years OR 2.17 (CI 1.01-4.66, p=0.047) and in males aged≥65 OR 3.50 (CI 1.55-7.82, p=0.002). Females were not at risk for lymphoma (figure 3).

This nationwide study suggests that exposure to anti-TNF therapy alone or in combination with thiopurines may be associated with an increased risk of lymphoma, but only in males, especially when last exposure occurred within 90 days.