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Climate change, described by the World Health Organization (WHO) in 2021 as 'the single biggest health threat facing humanity', causes extreme weather, disrupts food supplies, and increases the prevalence of diseases, thereby affecting human health, medical practice, and healthcare stability. Greener Gastroenterology is an important movement that has the potential to make a real difference in reducing the impact of the delivery of healthcare, on the environment. The WHO defines an environmentally sustainable health system as one which would improve, maintain or restore health while minimizing negative environmental impacts. Gastroenterologists encounter the impacts of climate change in daily patient care. Alterations in the gut microbiome and dietary habits, air pollution, heat waves, and the distribution of infectious diseases result in changed disease patterns affecting gastrointestinal and hepatic health, with particularly severe impacts on vulnerable groups such as children, adolescents, and the elderly. Additionally, women are disproportionally affected, since climate change can exacerbate gender inequalities. Paradoxically, while healthcare aims to improve health, the sector is responsible for 4.4% of global carbon emissions. Endoscopy is a significant waste producer in healthcare, being the third highest generator with 3.09 kg of waste per day per bed, contributing to the carbon footprint of the GI sector. Solutions to the climate crisis can offer significant health co-benefits. Steps to reduce our carbon footprint include fostering a Planetary Health Diet and implementing measures for greener healthcare, such as telemedicine, digitalization, education, and research on sustainable healthcare practices. Adhering to the principles of 'reduce, reuse, recycle' is crucial. Reducing unnecessary procedures, which constitute a significant portion of endoscopies, can significantly decrease the carbon footprint and enhance sustainability. This position paper by the United European Gastroenterology aims to raise awareness and outline key principles that the GI workforce can adopt to tackle the climate crisis together., (© 2024 The Author(s). United European Gastroenterology Journal published by Wiley Periodicals LLC on behalf of United European Gastroenterology.)

Introduction: Duplication of the appendix is a very rare presentation. According to the Cave-Wallbridge classification, there are three types of duplicate appendix., Presentation of Case: A 43 year old female presented with classical symptoms of acute appendicitis, with unremarkable inflammatory markers. The diagnosis was confirmed on pre-operative computer tomography (CT). During laparoscopy two tubular structures were identified: one arising from the tenia libera of the caecum adjacent to the terminal ileum and one retrocaecally at the confluence of the teniae. Both structures were excised using a laparoscopic linear stapler. Histopathological analysis demonstrated the accessory structure to be a microscopically unremarkable blind-ended tubular structure. The other specimen demonstrated acute gangrenous inflammation of the appendix. The patient had an uneventful recovery and was discharged home the following day., Discussion: Appendix duplication is rare; however, failure to recognise it in a patient with acute appendicitis could result in a retained source of sepsis, requiring subsequent re-exploration of the abdomen. The case presented here represents a Type B2 according to the Cave-Wallbridge classification and is the most susceptible to inadvertent error due to having appendixes in both typical and atypical anatomical locations. This case also highlights the probability of this diagnosis being missed on pre-operative CT., Conclusion: This case report presents a unique opportunity for surgical trainees to review intra-operative laparoscopic images of a duplicate appendix, both to allow them to recognise this pathology if encountered in the future, and to embed the importance of ruling it out with thorough intra-operative examination., Competing Interests: Conflict of interest statement Nothing to declare, (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: None declared

Introduction: The goal of this project was to create an up-to-date joint European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI), using the best available evidence. These guidelines are intended to help guide all medical professionals treating adult patients with FI (e.g., general practitioners, surgeons, gastroenterologists, other healthcare workers) and any patients who are interested in information regarding the diagnosis and management of FI., Methods: These guidelines have been created in cooperation with members from the United European Gastroenterology (UEG), European Society of Coloproctology (ESCP), European Society of Neurogastroenterology and Motility (ESNM) and the European Society for Primary Care Gastroenterology (ESPCG). These members made up the guideline development group (GDG). Additionally, a patient advisory board (PAB) was created to reflect and comment on the draft guidelines from a patient perspective. Relevant review questions were established by the GDG along with a set of outcomes most important for decision making. A systematic literature search was performed using these review questions and outcomes as a framework. For each predefined review question, the study or studies with the highest level of study design were included. If evidence of a higher-level study design was available, no lower level of evidence was sought or included. Data from the studies were extracted by two reviewers for each predefined important outcome within each review question. Where possible, forest plots were created. After summarising the results for each review question, a systematic quality assessment using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was performed. For each review question, we assessed the quality of evidence for every predetermined important outcome. After evidence review and quality assessment were completed, recommendations could be formulated. The wording used for each recommendation was dependent on the level of quality of evidence. Lower levels of evidence resulted in weaker recommendations and higher levels of evidence resulted in stronger recommendations. Recommendations were discussed within the GDG to reach consensus., Results: These guidelines contain 45 recommendations on the classification, diagnosis and management of FI in adult patients., Conclusion: These multidisciplinary European guidelines provide an up-to-date comprehensive evidence-based framework with recommendations on the diagnosis and management of adult patients who suffer from FI., (© 2022 The Authors. United European Gastroenterology Journal published by Wiley Periodicals LLC on behalf of United European Gastroenterology.)

Background & Aims: Anorectal manometry is a common test of anal tone and contractility. However, existing measures are often criticized for their poor ability to detect functional differences between individuals with presumably normal sphincter function and individuals with fecal incontinence. We investigated whether new measures, derived from high-resolution anal manometry (HR-ARM), more accurately identify incontinent women with abnormal sphincter function than measures from conventional anal manometry (C-ARM)., Methods: We performed a prospective HR-ARM study of 85 healthy female volunteers (median age 41 years; range 18-68 years) and 403 women with fecal incontinence (median age 55; range 18-91 years) from June 2013 through December 2015. We compared the diagnostic accuracy of conventional measurements of contractility (C-ARM squeeze increment) and tone (C-ARM resting pressure) (the reference standards), with HR-ARM measures (HR-ARM squeeze increment, HR-ARM contractile integral, HR-ARM resting average, HR-ARM rest integral). We also investigated associations between symptom severity and structural sphincter integrity., Results: We identified anal hypocontractility in 129 women with fecal incontinence using the C-ARM squeeze increment (32% sensitivity; likelihood ratio, 6.4), in 189 women using the HR-ARM squeeze increment (47% sensitivity; likelihood ratio, 9.4), and in 220 women using the HR-ARM contractile integral (55% sensitivity; likelihood ratio, 11.0). In contrast, HR-ARM measures of anal tone did not particularly outperform conventional measures (31% sensitivity for HR-ARM resting average vs 28% for C-ARM resting pressure). Ninety-eight of the 206 patients with fecal incontinence who were classified as having normal anal function, based on C-ARM measures, were reclassified as having abnormal function based on HR-ARM measures., Conclusion: In a prospective study of healthy women and women with fecal incontinence, we demonstrated that the newly developed HR-ARM contractile integral increased the sensitivity of detection of anal hypocontractility, from 32% to 55%, compared with conventional measurements of squeeze., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Introduction: Pelvic radiotherapy can cause anal stenosis. Patients can be left with severe rectal evacuatory difficulties, anal fissuring and resistant faecal incontinence. The management of such patients is difficult since surgical treatment can worsen faecal incontinence., Case Study: We report a patient who was treated for recurrent fissuring and faecal incontinence secondary to severe anal stenosis caused by external beam radiotherapy to his prostate. A 74-year-old male patient underwent excision of the fissuring, fibrotic anal mucosa and internal sphincter and was then treated with a broad-based House advancement anoplasty. The patient's fissuring was successfully treated but he still suffered from faecal incontinence. The patient underwent sacral nerve stimulation with significant improvement in all faecal incontinence symptoms., Conclusion: The use of a novel combination of a House advancement anoplasty and sacral nerve stimulation is a safe and effective treatment rationale for treatment of radiation-induced anal stenosis.