Hybrid endoscopic approaches for complex colorectal polyps with a non-lifting sign: the Greek experience.

Background: Hybrid approaches combining endoscopic full-thickness resection (EFTR) with conventional techniques (endoscopic mucosal resection [EMR], endoscopic submucosal dissection [ESD]) have enabled the resection of difficult fibrotic colorectal adenomas exhibiting a "non-lifting" sign, and polyps in difficult positions. We present our cohort treated with either EMR+EFTR or ESD+EFTR as salvage hybrid endoscopic approaches for complex colorectal polyps not amenable to conventional techniques. Methods: Retrospective analysis included technical success, histological confirmation of margin-free resection, assessment of adverse events and follow up with histological assessment. All patients underwent follow-up endoscopy at least 6 and 12 months post-resection. Results: Fourteen patients underwent hybrid EFTR procedures (11 EMR+EFTR and 3 ESD+EFTR). Technical success was achieved in all cases where the full-thickness resection device (FTRD) was advanced to the site of the resection (100%). In 2 cases, the FTRD system could not be passed through the sigmoid colon because of severe chronic diverticulitis, subsequent fibrosis and stiffness. The mean lesion size in the EMR+EFTR group (41.7 mm; range 20-50 mm) was larger than the ESD+EFTR group (31.7 mm; range 30-35 mm). Six patients (42.9%) were histologically diagnosed with T1 carcinoma. The mean duration of hospitalization was 1.4 days. Follow-up endoscopy was available in all patients and no recurrence was observed with histological confirmation during a mean follow-up period of 15.4 months. Conclusion: Hybrid procedures appear to be safe and effective treatments for complex colorectal lesions not amenable to EMR, ESD or EFTR alone, because of the lesion size, positive non-lifting sign, and difficult positions.

Long-term adenoma recurrence and development of colorectal cancer following endoscopic mucosal resection in large non-pedunculated colonic polyps ≥4 cm.

OBJECTIVES: Data of long-term follow up for large non pedunculated colorectal polyps (LNPCPs) ≥4 cm removed with piecemeal wide field endoscopic mucosal resection (PWF-EMR) are limited. We primarily evaluated the recurrence rates and secondarily the rates of post colonoscopic polypectomy colorectal cancer (PCPCRC) on a long-term basis. METHODS: We retrospectively reviewed a prospectively-stored electronic database of all patients who underwent PWF-EMR for LNPCPs at the Venizeleion General Hospital, between 2009 and 2020. Eligible patients were those with LNPCPs ≥4 cm, deemed completely removed by endoscopic means and followed-up for a minimum of 36 months with at least two surveillance colonoscopies, the first one (SC1) (4-6) months after the initial PWF-EMR procedure and the second one (SC2) after (12-18) months. In 2023, all cases were checked for PCPCRC development. RESULTS: Residual/early recurrent tissue was detected in 44 (31 %) cases among the 142 (82 males, 60 females) assessed during SC1. Late recurrent tissue was detected in 9 (6.6 %) cases among the 137 surveyed during SC2. Investigation did not reveal any case of PCPCRC . CONCLUSIONS: This historical cohort shows that the PWF-EMR for LNPCPs ≥4 cm is a safe and definitive removal method while it is not associated with the appearance of PCPCRC.

Endoscopic Postoperative Recurrence in Crohn's Disease After Curative Ileocecal Resection with Early Prophylaxis by Anti-TNF, Vedolizumab or Ustekinumab: A Real-World Multicentre European Study.

BACKGROUND: Endoscopic-post-operative-recurrence [ePOR] in Crohn's disease [CD] after ileocecal resection [ICR] is a major concern. We aimed to evaluate the effectiveness of early prophylaxis with biologics and to compare anti-tumour necrosis factor [anti-TNF] therapy to vedolizumab [VDZ] and ustekinumab [UST] in a real-world setting. METHODS: A retrospective multicentre study of CD-adults after curative ICR on early prophylaxis was undertaken. ePOR was defined as a Rutgeerts score [RS] ≥ i2 or colonic-segmental-SES-CD ≥ 6. Multivariable logistic regression was used to evaluate risk factors, and inverse probability treatment weighting [IPTW] was applied to compare the effectiveness between agents. RESULTS: The study included 297 patients (53.9% males, age at diagnosis 24 years [19-32], age at ICR 34 years [26-43], 18.5% smokers, 27.6% biologic-naïve, 65.7% anti-TNF experienced, 28.6% two or more biologics and 17.2% previous surgery). Overall, 224, 39 and 34 patients received anti-TNF, VDZ or UST, respectively. Patients treated with VDZ and UST were more biologic experienced with higher rates of previous surgery. ePOR rates within 1 year were 41.8%. ePOR rates by treatment groups were: anti-TNF 40.2%, VDZ 33% and UST 61.8%. Risk factors for ePOR at 1 year were: past-infliximab (adjusted odds ratio [adj.OR] = 1.73 [95% confidence interval, CI: 1.01-2.97]), past-adalimumab [adj.OR = 2.32 [95% CI: 1.35-4.01] and surgical aspects. After IPTW, the risk of ePOR within 1 year of VDZ vs anti-TNF or UST vs anti-TNF was comparable (OR = 0.55 [95% CI: 0.25-1.19], OR = 1.86 [95% CI: 0.79-4.38]), respectively. CONCLUSION: Prevention of ePOR within 1 year after surgery was successful in ~60% of patients. Patients treated with VDZ or UST consisted of a more refractory group. After controlling for confounders, no differences in ePOR risk were seen between anti-TNF prophylaxis and other groups.

IgG4-related sclerosing cholangitis: not always an obvious entity.

Immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) is a distinct type of cholangitis, currently recognized as a biliary manifestation of IgG4-related disease. We present a case of type 3 IgG4-SC in a patient with normal IgG4 serum levels, surgically treated for suspicion of cholangiocarcinoma. This case highlights that differentiating between isolated IgG4-SC and cholangiocarcinoma can present a challenging diagnostic dilemma.

Paradigm shift in management of acute iatrogenic colonic perforations: 24-year retrospective comprehensive study.

Background and study aims Through advanced endoscopic clipping techniques, endoscopic treatment of both diagnostic and therapeutic acute iatrogenic colonic perforations has been shown effective. The main purpose of this study was to compare the management of acute iatrogenic perforations (AIPs) of the colon before and after the introduction of advanced clipping techniques. Methods We conducted a retrospective study from July 1996 to February 2020. The period was divided into two sub periods, Period 1: from July 1996 to December 2012 and Period 2: from January 2013 to March 2020. All AIPs occurring during a colonoscopy and detected during or immediately (< 4 hours) after the procedure, were included in the study. Results The total number of colonoscopies performed at our hospital was 33055 and 36831 during Periods 1 and 2 respectively. Fifteen perforations were observed in Period 1 and 11 in Period 2. The rate of surgery was 93.3 % % (14/15) in Period 1 and 27.2 % (3 /11) in Period 2 ( P  < 0.01). The mean hospital stay in Period 1 was 6.9 days and 4 in Period 2 ( P  < 0.01). Conclusions Data from this historical cohort have clearly shown a decrease in the surgery rate and the length of hospitalization of AIPs in Period 2 compared to Period 1.

Age, Comorbidities and Fear of Fall: mortality predictors associated with fall-related fractures.

Objectives: To determine mortality predictors following fall related fractures in older patients. Materials and methods: Patients aged ≥ 70 years hospitalized for fall related fractures were prospectively evaluated. Mortality was the main outcome. Age, functional-cognitive function, medications, comorbidities, fall history, fear of falls were also assessed. Outcomes: A total of 100 patients were enrolled. Ninety-one out of 100 (91%) suffered a hip fracture; 92 (92%) had surgery. The one-year post-discharge mortality was 20%. Univariate analysis revealed that older age, increased Charlson comorbidity index, low abbreviated mental test on admission, low modified Barthel index (MBI), fear of falls and delirium were significantly correlated with one-year post discharge mortality (p=.03, p=.003, p=.04, p=.005, p=.004, p=.015, respectively). Conclusion: Age, fear of falls and Charlson comorbidity index are predictors of one-year mortality after hospitalization for fracture. It is of utmost importance to identify older patients suffering from fracture at risk of dying that may benefit from patient-centered care.

Disseminated metastatic cutaneous melanoma to pancreas and upper gastrointestinal tract diagnosed by endoscopic ultrasound: an unusual case.

There is a wide variety of pancreatic neoplasms identified, but the great majority of them are of primary origin. Metastatic disease in the pancreatic parenchyma is quite rare (2-5% of pancreatic malignancies) and most often is quite difficult to differentiate from other primary lesions. Most of the imaging studies fail to give certain discriminating features for metastatic pancreatic neoplasms, contrary to endoscopic ultrasound and tissue sampling, which can provide an accurate diagnosis. In this report, we present a case of a male middle aged man who was admitted to our hospital with painless jaundice and finally was diagnosed with a cutaneous scalp melanoma dispersedly metastasized to the pancreas and upper gastrointestinal tract (stomach and duodenum).

Endoscopic full-thickness resection of colorectal lesions with the full-thickness resection device: clinical experience from two referral centers in Greece.

BACKGROUND: Endoscopic full-thickness resection (EFTR) using the full-thickness resection device (FTRD®) is an invasive treatment for colorectal lesions not resectable by conventional endoscopic techniques. This study presents the first Greek experience of the FTRD® procedure, assessing the efficacy and safety of EFTR. METHODS: We conducted a retrospective analysis of 17 consecutive patients treated with the FTRD® at 2 referral centers from October 2015 through December 2018. The indications included difficult adenomas (non-lifting and/or at difficult locations), early adenocarcinomas and subepithelial tumors. Primary endpoints were technical success and R0 resection. RESULTS: Technical success and R0 resection were achieved in 82.3% procedures (14/17) and in 87.5% of those with difficult adenomas (8 patients). In the subgroup with carcinomas (n=3), the rate of technical success and R0 resection was 66.6%, while in the subgroup with subepithelial tumors (n=6) the rate was 83.3%. Technical success and R0 resection were significantly lower for lesions >20 mm vs. ≤20 mm (P=0.0429). In the 17 patients a total of 3 adverse events occurred (17.6%) and one of the patients underwent laparoscopic appendectomy because of EFTR around the appendix. CONCLUSIONS: Our study showed favorable results concerning EFTR feasibility, efficacy and safety, especially for lesions ≤20 mm, non-lifting adenomas, and subepithelial tumors. Technical success, R0 resection, and adverse events rates were comparable with previously published data. Larger randomized studies are needed to better define the clinical benefit and long-term outcomes of EFTR in selected patients.

PLA2R-Negative Membranous Nephropathy Presenting as a Prodrome of IgG4-Related Autoimmune Pancreatitis.

Membranous nephropathy (MN) with tubulointerstitial nephritis (TIN) is an established manifestation of immunoglobulin G4 (IgG4)-related disease (IgG4-RD). A pathological feature aiming to distinguish between primary and secondary MN is the presence or absence of glomerular staining for phospholipase A2 receptor (PLA2R), respectively. Isolated MN without TIN has been rarely reported in the context of IgG4-RD. This case report describes a patient with a history of MN successfully treated with steroids and cyclophosphamide, who, 3 years later, presented with unexplained exacerbation of diabetes mellitus due to IgG4-related autoimmune pancreatitis. Pancreatitis was treated, and diabetes improved after treatment with steroids. Based on the presence of isolated IgG4 glomerular capillary deposits along with negative staining for PLA2R and the metachronous appearance of autoimmune pancreatitis, MN was retrospectively classified as secondary to IgG4-RD. Isolated IgG4-positive/PLA2R-negative MN without TIN can be a prodrome of IgG4-RD, reminiscent of MN secondary to neoplasms.

Complete endoscopic mucosal resection of malignant colonic sessile polyps and clinical outcome of 51 cases.

BACKGROUND: Meta-analyses and guidelines recommend that deep submucosal invasion (>1 mm) of malignant sessile colonic polyps is an important risk factor for lymph node metastasis. However, existing data are based on small retrospective studies with marked heterogeneity. We herein aimed to investigate the long-term outcomes of patients who underwent complete endoscopic mucosal resection (EMR) of malignant colonic sessile polyps invading the submucosal layer. METHODS: Endoscopy records for the period 2000-2016 were reviewed retrospectively. All enrolled patients exhibited an endoscopically resected malignant colonic sessile polyp. All patients were advised to undergo surgery, but some opted for conservative treatment and endoscopic follow up. RESULTS: Fifty-one patients with confirmed infiltrative submucosal adenocarcinoma in sessile colonic polyps that had undergone complete EMR were detected. A total of 32 (62.7%) patients opted for surgery after EMR and 19 (37.3%) chose endoscopic follow up. In 44 (86.3%) patients the submucosal invasion was >1 mm. Residual malignant disease was identified in the surgical pathological specimen of only 1 patient. During a median follow up of 23.41 months (interquartile range 33.45, range 1.84-144.92), no local recurrences or lymph node metastasis were identified. Forty-nine patients are alive without evidence of disease and 2 died of other causes (without evidence of local or metastatic disease at last follow up). CONCLUSION: Our data suggest that complete EMR of cancerous colonic sessile polyps, even in cases of submucosal invasion >1 mm carries a low risk of recurrence and therefore may need further evaluation as an alternative strategy to surgical resection.

Large adrenal cyst masquerading as a pancreatic cystic tumor: a rare diagnosis based on endoscopic ultrasound.

Adrenal cystic lesions constitute a rare finding and usually are diagnosed incidentally as retroperitoneal cysts during imaging studies. A major issue, especially for the large-sized ones, is their preoperative diagnosis and management, as imaging modalities often fail to detect their exact origin prior to surgery. We report a case of a big adrenal cyst that was mistakenly diagnosed and followed up as pancreatic cystic tail tumor. Our thorough workup, which included endoscopic ultrasound (EUS), managed to delineate an adrenal gland-originated cyst and altered further management of the patient. According to our knowledge, this is the first report in literature in which EUS proved its superiority over other imaging studies in clarifying the origin of an ambiguous big retroperitoneal cyst. We believe that for cases of large retroperitoneal cystic lesions, EUS consists the optimal diagnostic and sampling tool.