Cold Vs Hot Snare Endoscopic Resection of Large Nonpedunculated Colorectal Polyps: Randomized Controlled German CHRONICLE Trial.

BACKGROUND & AIMS: Endoscopic mucosal resection (EMR) is standard therapy for nonpedunculated colorectal polyps ≥20 mm. It has been suggested recently that polyp resection without current (cold resection) may be superior to the standard technique using cutting/coagulation current (hot resection) by reducing adverse events (AEs), but evidence from a randomized trial is missing. METHODS: In this randomized controlled multicentric trial involving 19 centers, nonpedunculated colorectal polyps ≥20 mm were randomly assigned to cold or hot EMR. The primary outcome was major AE (eg, perforation or postendoscopic bleeding). Among secondary outcomes, major AE subcategories, postpolypectomy syndrome, and residual adenoma were most relevant. RESULTS: Between 2021 and 2023, there were 396 polyps in 363 patients (48.2% were female) enrolled for the intention-to-treat analysis. Major AEs occurred in 1.0% of the cold group and in 7.9% of the hot group (P = .001; odds ratio [OR], 0.12; 95% CI, 0.03-0.54). Rates for perforation and postendoscopic bleeding were significantly lower in the cold group, with 0% vs 3.9% (P = .007) and 1.0% vs 4.4% (P = .040). Postpolypectomy syndrome occurred with similar frequency (3.1% vs 4.4%; P = .490). After cold resection, residual adenoma was found more frequently, with 23.7% vs 13.8% (P = .020; OR, 1.94; 95% CI, 1.12-3.38). In multivariable analysis, lesion diameter of ≥4 cm was an independent predictor for major AEs (OR, 3.37) and residual adenoma (OR, 2.47) and for high-grade dysplasia/cancer for residual adenoma (OR, 2.92). CONCLUSIONS: Cold resection of large, nonpedunculated colorectal polyps appears to be considerably safer than hot EMR; however, at the cost of a higher residual adenoma rate. Further studies have to confirm to what extent polyp size and histology can determine an individualized approach. German Clinical Trials Registry (Deutsches Register Klinischer Studien), Number DRKS00025170.

Comparative proteomics reveals different protein expression in platelets in patients with alcoholic liver cirrhosis.

BACKGROUND: The role of platelets in disease progression as well as the function of platelets as part of the haemostatic and immunological system in patients with liver cirrhosis is only incompletely understood. This is partly due to difficulties in assessing platelet function. Proteome analyses of platelets have been used to further investigate the role of platelets in other diseases. AIM: To assess possible changes in the platelet proteome during different stages of alcohol induced liver cirrhosis compared to healthy donors. PATIENTS AND METHODS: A 45 ml blood sample was drawn from 18 participants aged 18-80 years evenly divided into three groups of healthy donors, patients with less advanced alcohol induced liver cirrhosis (Child-Pugh < 7) and patients with advanced liver cirrhosis (Child-Pugh > 10). The blood was processed to isolate platelets and perform subsequent two-dimensional gel-electrophoresis using a SYPRO™ Ruby dye. After computational analysation significantly in- or decreased protein spots (defined as a two-fold abundance change between different study cohorts and ANOVA < 0.05) were identified via liquid chromatography-mass spectrometry (LCMS) and searching against human protein databases. RESULTS: The comparative analysis identified four platelet proteins with progressively decreased protein expression in patients with liver cirrhosis. More specifically Ras-related protein Rab-7a (Rab-7a), Ran-specific binding protein 1 (RANBP1), Rho GDP-dissociation inhibitor 1 (RhoGDI1), and 14-3-3 gamma. CONCLUSION: There is significant change in protein expression in the platelet proteome throughout the disease progression of alcohol induced liver cirrhosis. The identified proteins are possibly involved in haemostatic and immunoregulatory function of platelets.

Prospective randomized controlled trial comparing a novel and dedicated device with conventional endoscopic techniques for the treatment of buried bumper syndrome (with video).

BACKGROUND AND AIMS: Buried bumper syndrome (BBS) is a rare adverse event of PEG tubes. This study compared the newly developed Flamingo device (Fujifilm Medwork GmbH, Höchstadt, Germany) with conventional endoscopic techniques for BBS treatment. METHODS: This prospective, randomized controlled trial compared the Flamingo set (study group) with other endoscopic techniques (control group) for BBS treatment in 6 German hospitals. The primary endpoint was procedure time. Further outcome parameters were technical success, adverse event rate, and number and cost of devices used in each group. RESULTS: Thirty-six patients (18 in each group; mean age, 73 years; 12 women) were included in this study between March 2018 and December 2022. Median time since placement of the feeding tube was 30 months. The bumper was located in the gastric corpus in 27 patients, and the internal bumper was completely overgrown in 31 patients. The duration of the removal procedure was 17 minutes (range, 3-72) in the study group compared with 38 minutes (range, 12-111) in the control group (P = .046). The primary technical success rate was 77.8% in the study group and 55.6% in the control group (P = .157), whereas the overall technical success rate was 100% compared with 83.3% (P = .070). Adverse events occurred in 4 patients (11.1%). CONCLUSIONS: Endoscopic removal of the buried bumper using the Flamingo device was significantly faster than that with other endoscopic techniques and showed a higher technical success rate. This device may become the endoscopic treatment of choice for BBS. (Clinical trial registration number: NCT03186066.).

Endoscopic Submucosal Dissection for Early Esophageal Adenocarcinoma: Low Rates of Metastases in Mucosal Cancers with Poor Differentiation.

BACKGROUND AND AIMS: Endoscopic resection (ER) is accepted as standard treatment for intramucosal esophageal adenocarcinoma (EAC) with well or moderate differentiation. Poor differentiation (PD) is judged as a risk factor for lymph node metastasis (LNM) and surgery is recommended. However, the evidence for this recommendation is weak. Study aim was to analyze the clinical course of patients after ER of EAC with PD. PATIENTS AND METHODS: Patients undergoing endoscopic submucosal dissection for EAC were included from 16 German centers. Inclusion criteria were PD in the resection specimen, R0 resection and endoscopic follow-up. Primary outcome was the metastasis rate during follow-up. Analysis was performed retrospectively in a prospectively collected database. RESULTS: 25 patients with PD as single risk factor (group A) and 15 patients with PD and additional risk factors (submucosal invasion and/or lymphovascular invasion) were included. The metastasis rate was was 1/25 (4.0%; 95%CI 0.4-17.2) in group A and 3/15 (20.0%; 95%CI 6.0-44.4%) in group B, respectively (p=0.293). The rate of EAC-associated deaths was 1/25 (4%; 95%CI 0.4-17.2%) versus 3/15 (20%; 95%CI 6.0-44.4%) in group B (p=0.293) while the overall death rate was 7/25 (28.0%; 95%CI 13.5-47.3%) versus 3/15 (20%; 95%CI 6.0-44.4%) (p=0.715). Median follow-up was 30 months (IQR 15-53). CONCLUSIONS: During long-term follow-up the risk of metastasis is low after ER of mucosal EAC with PD as single risk factor. A conservative approach seems justified in this small patient group. However, the treatment strategy has to be determined on an individualized basis until further prospective data are available.

Propensity score-matched retrospective cohort study of endoscopic ultrasound-guided gastroenterostomy and enteral stenting for malignant gastric outlet.

BACKGROUND: Symptomatic malignant gastric outlet obstruction (GOO) significantly reduce patients' quality of life. Endoscopic treatment involves enteral stenting or endoscopic ultrasonography to perform gastroenterostomy (EUS-GE). Aim was to compare enteral stenting with EUS-GE for endoscopic treatment of malignant GOO. METHODS: We retrospectively compared enteral stenting with EUS-GE for the treatment of malignant GOO. Patients treated at our institution were identified and a propensity score matching analysis was performed. Treatment failure was the primary outcome, while the secondary endpoints were time until treatment failure, technical and clinical success rates, and adverse event rates. RESULTS: Eighty-eight patients were included in the final analysis. Of whom, 44 were included in each of the two treatment groups. Treatment failure occurred significantly more frequently in the enteral stenting group (13/44) compared with the EUS-GE group (4/44; hazard ratio: 4,9; 95% CI 1.6-15.1). A Kaplan-Meier analysis revealed a median time until treatment failure of 22.0 weeks (95% CI 4.6-39.4) in the enteral stenting group compared with 76.0 weeks (95% CI 55.9-96.1) in the EUS-GE group (P = .002). No difference in technical success and clinical success was detected. Technical success was achieved in 43/44 patients (97.7%) in the enteral stenting group compared with 41/44 patients (93.2%) in the EUS-GE group, while clinical success was achieved in 32/44 (72.7%) and 35/44 (79.5%) patients, respectively. Nine adverse events were observed (9/44, 10.2%). There were no differences in 30-day adverse event rate and 30-day mortality rate. CONCLUSION: EUS-GE was superior to enteral stenting in the treatment of malignant GOO in terms of treatment failure and time until treatment failure in a propensity score-matched cohort.

[Endoscopic Diagnosis and Treatment of Early Mucosal Neoplasms in the Oesophagus]. / Endoskopische Diagnostik und Therapie von malignen epithelialen Läsionen und ihren Vorläufern im Ösophagus.

Endoscopy is the gold standard for diagnosis of oesophageal cancer and its precursor lesions. Besides this, endoscopy treatment of these precursor lesions and early oesophageal cancer has been well evaluated and established. This includes dysplastic lesions associated with Barrett's oesophagus and early adenocarcinoma, as well as early squamous cell cancer of the oesophagus. The role of endoscopy for diagnosis and treatment of these lesions is summarised.

Efficacy and safety of combined EMR and endoscopic full-thickness resection (hybrid EFTR) for large nonlifting colorectal adenomas.

BACKGROUND AND AIMS: Endoscopic full-thickness resection (EFTR) with a full-thickness resection device (FTRD) has become the standard technique for selected nonlifting colorectal adenomas, but tumor size is the major limitation. However, large lesions might be approached in combination with EMR. Herein, we report the largest single-center experience to date of combined EMR and EFTR (hybrid EFTR) in patients with large (≥25 mm) nonlifting colorectal adenomas not amenable to EMR or EFTR alone. METHODS: This is a single-center retrospective analysis of consecutive patients who underwent hybrid EFTR of large (≥25 mm) nonlifting colorectal adenomas. Outcomes of technical success (successful advancement of the FTRD with consecutive successful clip deployment and snare resection), macroscopic complete resection, adverse events, and endoscopic follow-up were evaluated. RESULTS: Seventy-five patients with nonlifting colorectal adenomas were included. Mean lesion size was 36.5 mm (range, 25-60 mm), and 66.6% were located in the right side of the colon. Technical success was 100% with macroscopic complete resection in 97.3%. Mean procedure time was 83.6 minutes. Adverse events occurred in 6.7%, leading to surgical therapy in 1.3%. Histology revealed T1 carcinoma in 16%. Endoscopic follow-up was available in 93.3% (mean follow-up time, 8.1 months; range, 3-36) and showed no signs of residual or recurrent adenoma in 88.6%. Recurrence (11.4%) was treated endoscopically. CONCLUSIONS: Hybrid EFTR is safe and effective for advanced colorectal adenoma that cannot be approached by EMR or EFTR alone. Hybrid EFTR expands the indication of EFTR substantially in selected patients.

Reduced mortality for over-the-scope clips (OTSC) versus surgery for refractory peptic ulcer bleeding: a retrospective study.

BACKGROUND: Surgery or transcatheter arterial embolization or are both considered as standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-The-Scope clips (OTSC) have shown superiority to standard endoscopic treatment but a comparison with surgery has not been performed, yet. PATIENTS AND METHODS: In this retrospective, multicenter study, 103 patients treated with OTSC (n = 66) or surgery (n = 37) for refractory PUB in four tertiary care centers between 2009 and 2019 were analyzed. Primary endpoint was clinical success (successful hemostasis and no rebleeding within seven days). Secondary endpoints were adverse events, length of ICU-stay and in-hospital mortality. Univariable and multivariable regression models were performed to define predictive factors for allocation to surgical therapy and for mortality. RESULTS: Age, comorbidities, anticoagulation therapy, number of pretreatments, ulcer location, and Rockall-Score were similar in both groups. In the surgical group, there were significantly more patients in shock at rebleeding (78.1% vs. 43.9%; p = 0.002), larger ulcers (18.6 ± 7.4 mm vs. 23.0 ± 9.4 mm; p = 0.017) and more FIa bleedings (64.9% vs. 19.7%; p < 0.001) were detected. Clinical success was comparable (74.2% vs. 83.8%; p = 0.329). In the surgical group, length of ICU-stay (16.2 ± 18.0 days vs. 4.7 ± 6.6 days; p < 0.001), severe adverse events (70.3% vs. 4.5%; p < 0.001) and in-hospital mortality (35.1% vs. 9.1%; p = 0.003) were significantly higher. Multivariable analysis defined shock at rebleeding as the main predictor for allocation to surgical therapy (OR 4.063, 95%CI {1.496-11.033}, p = 0.006). Postsurgical adverse events were the main reason for the in-hospital mortality (OR 5.167, 95% CI {1.311-20.363}, p = 0.019). CONCLUSION: In this retrospective study, OTSC compared to surgical treatment showed comparable clinical success but was associated with shorter ICU-stay, less severe adverse events and lower in-hospital mortality.

Over-the-scope-clips versus standard treatment in high-risk patients with acute non-variceal upper gastrointestinal bleeding: a randomised controlled trial (STING-2).

OBJECTIVE: Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is managed by standard endoscopic combination therapy, but a few cases remain difficult and carry a high risk of persistent or recurrent bleeding. The aim of our study was to compare first-line over-the-scope-clips (OTSC) therapy with standard endoscopic treatment in these selected patients. DESIGN: We conducted a prospective, randomised, controlled, multicentre study (NCT03331224). Patients with endoscopic evidence of acute NVUGIB and high risk of rebleeding (defined as complete Rockall Score ≥7) were included. Primary endpoint was clinical success defined as successful endoscopic haemostasis without evidence of recurrent bleeding. RESULTS: 246 patients were screened and 100 patients were finally randomised (mean of 5 cases/centre and year; 70% male, 30% female, mean age 78 years; OTSC group n=48, standard group n=52). All but one case in the standard group were treated with conventional clips. Clinical success was 91.7% (n=44) in the OTSC group compared with 73.1% (n=38) in the ST group (p=0.019), with persistent bleeding occurring in 0 vs 6 in the OTSC versus standard group (p=0.027), all of the latter being successfully managed by rescue therapy with OTSC. Recurrent bleeding was observed in four patients (8.3%) in the OTSC group and in eight patients (15.4%) in the standard group (p=0.362). CONCLUSION: OTSC therapy appears to be superior to standard treatment with clips when used by trained physicians for selected cases of primary therapy of NVUGIB with high risk of rebleeding. Further studies are necessary with regards to patient selection to identify subgroups benefiting most from OTSC haemostasis. TRIAL REGISTRATION NUMBER: NCT03331224.

Impact of endobiliary radiofrequency ablation on biliary drainage in patients with malignant biliary strictures treated with uncovered self-expandable metal stents: a randomized controlled multicenter trial.

BACKGROUND AND AIMS: Endobiliary radiofrequency ablation (RFA), usually combined with endoscopic stent insertion, is a simple procedure with the potential to improve stent patency and patient survival for malignant biliary obstruction. We conducted this randomized multicenter trial to evaluate the impact of RFA on stent patency. METHODS: Eighty-six patients with malignant biliary obstruction and nonresectable tumors (pancreatic carcinoma, cholangiocarcinoma, or metastases) were included and randomly assigned to receive a self-expandable metal stent (SEMS) only (n = 44) or RFA followed by SEMS insertion (RFA+SEMS, n = 42). The primary outcome measure was stent patency after 3 and 6 months; secondary outcome measures were patient survival and early adverse events within 30 days. RESULTS: Technical success rates for RFA and stent insertion were 100% and 98.8%, respectively. Stent patency after 3 and 6 months did not differ significantly between groups (RFA+SEMS group, 73.1% and 33.3%, respectively; SEMS-only group, 81.8% and 52.4%, respectively; P = .6). Similarly, the addition of RFA did not impact overall survival (hazard ratio, .72; P = .389 for RFA+SEMS). The adverse event rate in the RFA+SEMS group was 10.5% compared with 2.3% in the SEMS-only group, without a statistically significant difference (P = .18). CONCLUSIONS: RFA as an addition to SEMS implantation had no positive impact on patency rate or survival. (Clinical trial registration number: DRKS00018993.).

Systematic review and meta-analysis on effectiveness and safety of the full-thickness resection device (FTRD) in the colon.

BACKGROUND: Endoscopic full-thickness resection (EFTR) has expanded the possibilities of endoscopic resection. The full-thickness resection device (FTRD, Ovesco Endoscopy, Tübingen, Germany) combines a clip-based defect closure and snare resection in a single device. METHODS: Systematic review and meta-analysis on effectiveness and safety of the FTRD in the colon. RESULTS: A total of 26 studies (12 published as full-text articles and 14 conference papers) with 1538 FTRD procedures were included. The pooled estimate for reaching the target lesion was 96.1 % (95 % confidence interval [95 % CI]: 94.6-97.1) and 90.0 % (95 % CI: 87.0-92.3) for technically successful resection. Pooled estimate of histologically complete resection was 77.8 % (95 % CI: 74.7-80.6). Adverse events occurred at a pooled estimate rate of 8.0 % (95 % CI: 5.8-10.4). Pooled estimates for bleeding and perforation were 1.5 % (95 % CI: 0.3-3.3) and 0.3 % (95 % CI: 0.0-0.9), respectively. The rate for need of emergency surgery after FTRD was 1.0 % (95 % CI: 0.4-1.8). CONCLUSION: The use of the FTRD in the colon shows very high rates of technical success and complete resection (R0) as well as a low risk of adverse events. Emergency surgery after colonic FTRD resection is necessary in single cases only.

Telemetric capsule-based upper gastrointestinal tract - blood detection - first multicentric experience.

INTRODUCTION: Risk stratification in upper gastrointestinal bleeding (UGIB) currently relies on clinical parameters and risk scores. HemoPill® acute (Ovesco Endoscopy, Tuebingen, Germany) is a pill-shaped, orally administered sensor capsule for real-time blood detection. The aim of this study was to evaluate the system in clinical routine. MATERIAL AND METHODS: Sixty-one consecutive patients in whom the HemoPill® had been used at 12 international hospitals between July 2019 and March 2020 were retrospectively analysed. Indications for application were the clinical suspicion of UGIB, small bowel bleeding, of rebleeding after hemostasis. Primary endpoints were technical success and bleeding detection/exclusion. Secondary endpoints included adverse events and change of clinical course. RESULTS: The capsule was used in 45 (73%) patients with UGIB, in 12 (20%) patients with small bowel bleeding and in four (7%) patients for exclusion of rebleeding. Technical success was 98%. 35/60 (58%) cases were capsule-positive and among these, endoscopy showed bleeding in 20/35 (57%) cases. None of the 25 capsule-negative patients rebled. Emergency endoscopy could be avoided in 18/25 (72%) cases. Serious adverse events did not occur. CONCLUSION: HemoPill®-based blood detection is feasible and safe. Negative capsule results might 'downgrade' the need for urgent endoscopy.

Risk of appendicitis after endoscopic full-thickness resection of lesions involving the appendiceal orifice: a retrospective analysis.

BACKGROUND: Conventional endoscopic resection of lesions affecting the appendiceal orifice is difficult. Endoscopic full-thickness resection (EFTR) is a novel technique in interventional endoscopy. As EFTR near the appendiceal orifice is associated with a subtotal appendectomy, it remains unclear whether the risk of developing appendicitis is increased. We conducted a retrospective analysis of lesions involving the appendiceal orifice treated by EFTR. METHODS: This was a multicenter retrospective analysis of patients (n = 50) treated with EFTR for lesions involving the appendiceal orifice between 2014 and 2019. The objective was to evaluate the occurrence of appendicitis. RESULTS: Acute appendicitis occurred in seven patients (14 %) during follow-up. Conservative treatment was sufficient in four cases, and three patients underwent appendectomy. CONCLUSIONS: EFTR of lesions involving the appendiceal orifice may be associated with an imminent risk of developing appendicitis and a consecutive need for appendectomy. Patients should be informed about this specific risk prior to resection. It is unclear why some patients develop appendicitis while the majority remains asymptomatic.

Endoscopic gastrointestinal anastomoses with lumen-apposing metal stents: predictors of technical success.

BACKGROUND: Lumen-apposing metal stents (LAMS) may be inserted to create gastrointestinal anastomoses under endoscopic ultrasound (EUS) guidance. This new technique has mostly been evaluated as treatment for gastric outlet obstruction (GOO), especially of malignant origin. Technical success was high in the few and small available studies. Aim of this study was to report our experience with this technique and to identify predictors of success in the setting of a large teaching hospital in Germany. METHODS: All subsequent patients who underwent EUS-guided gastrointestinal anastomosis with LAMS from 02/2016 to 08/2019 were included. We performed a retrospective chart analysis including technical procedural details, basic demographic, and health characteristics. Technical success was defined as successful insertion of LAMS. In patients with GOO, the GOO Scoring System was used; an improvement ≥ 1 point was defined as clinical success. RESULTS: Thirty-five patients (22 female, median age: 79 years) were included. Indication for the anastomosis was malignant GOO in 33 patients. In ten patients LAMS was inserted over a guidewire, in 22 patients direct puncture with the electrocautery delivery system of LAMS was performed, and other techniques were used in two patients. Technical success rate was 80.0%. Adverse events occurred in 14.3%. Clinical success rate was 74.3%. Technical success increased and procedure time decreased significantly during the study period. Distance between the two lumina connected with LAMS was significantly shorter (median: 9 mm) in patients with technical success compared to those without (median: 20 mm, P = 0.004). This distance was identified as predictor of success on multivariate analysis. CONCLUSIONS: EUS-guided gastrointestinal anastomosis with LAMS is an emerging technique. Its success mainly depends on the distance between the two lumina that are going to be connected by the LAMS and is influenced by the endoscopist's experience.

EUS-directed transenteric ERCP in non-Roux-en-Y gastric bypass surgical anatomy patients (with video).

BACKGROUND AND AIMS: Enteroscopy-assisted ERCP is challenging in patients with surgically altered upper GI anatomy. This study evaluated a novel procedure, EUS-directed transenteric ERCP (EDEE), in the de novo creation of an enteroenteric anastomosis for the performance of ERCP in non-Roux-en Y gastric bypass (RYGB) patients. METHODS: This was a multicenter retrospective study involving 7 centers between January 2014 and October 2018. Primary outcome was clinical success (completion of EDEE and ERCP with intended interventions), and secondary outcomes were technical success and rate/severity of adverse events. RESULTS: Eighteen patients (mean age, 63 years; 13 women) were included. The most common type of surgical anatomy was Whipple (10/18) and Roux-en-Y hepaticojejunostomy (6/18). Technical success rate of EUS-guided lumen-apposing metal stent (LAMS) placement was 100% and of ERCP was 94.44% (17/18). Fourteen patients underwent separate-session EDEE with a median of 21 days (interquartile range [IQR], 11.5-36) between the 2 procedures. Median total procedure time was 111 minutes (IQR, 81-192). Clinical success and adverse events occurred in 17 (94.4%) and 1 (5.6%; abdominal pain) patients, respectively, during a median follow-up of 88 days (IQR, 54-142). CONCLUSIONS: This study suggests that EDEE using LAMSs is feasible and safe in patients with non-RYGB surgical anatomy and complex pancreaticobiliary pathologies.

Endoscopic full-thickness resection of gastric subepithelial tumors with the gFTRD-system: a prospective pilot study (RESET trial).

BACKGROUND: Gastric subepithelial tumors (SET) are rare and usually benign. However, up to 13% are malignant. Histology after conventional biopsy often is inconclusive. Surveillance endoscopies are the consequence in the majority of gastric SET cases. For SET arising from deeper layers endoscopic resection (ER) with the standard techniques is difficult and associated with the risk of perforation. The RESET trial further evaluates feasibility, efficacy and safety of clip-assisted endoscopic full-thickness resection (EFTR) for gastric SET using the novel gastric full-thickness-resection device (gFTRD). MATERIALS AND METHODS: The RESET trial was initiated in March 2017 (NCT03096236) and designed as prospective observational multicenter pilot trial. Gastric SET up to 15 mm were included. Primary endpoint was technical success (complete enbloc resection). Secondary endpoints were R0 resection, full-thickness resection, adverse events and recurrency at 3-months follow-up. For resection we used the gFTRD (Ovesco Endoscopy, Tübingen, Germany). RESULTS: 29 patients underwent gastric EFTR. Histology prior EFTR after conventional biopsy could define histological tumor type in only 31.2%. Primary endpoint was reached in 89.7%. Histology of the full-thickness-resection specimen could define histological tumor type in 100%. 76% of all SET could be resected histologically complete (R0) and a full-thickness-resection specimen could be obtained in 65.5%. In 31% periprocedural minor bleeding was observed and managed endoscopically. Follow-up was available in 79.3% (OTSC detachment in 78.3%, OTSC in position in 21.7%). No signs of residual or recurrent tumors were observed after 3 months. CONCLUSION: EFTR of gastric SET with gFTRD is feasible and safe. EFTR allows a definite histological diagnosis (including sufficient risk stratification in case of GIST or NET) in contrast to conventional biopsy. R0-resection is possible in most cases and might obviate the need for further surveillance endoscopies for selected patients.

A novel device for the endoscopic management of buried bumper syndrome.

BACKGROUND: Buried bumper syndrome (BBS) is a complication of percutaneous endoscopic gastrostomy (PEG) in which the internal bumper is overgrown by the gastric mucosa. Apart from loss of patency of the PEG tube, the buried bumper may evoke symptoms such as abdominal pain or peritubular leakage. While the management of an incompletely buried bumper is fairly straightforward, this is not the case for a completely buried bumper. Different approaches to remove completely buried bumpers have been described, including endoscopic knife- or papillotome-based techniques. However, these devices are used off-label and the procedures can be laborious. METHODS: The Flamingo device has recently been introduced as the first tool specifically designed to remove a completely buried bumper. RESULTS: We describe the technique and our first experience in five patients with a completely (n = 4) or almost completely (n = 1) buried bumper. Fast and save removal of the buried bumper was obtained in all patients. CONCLUSION: We believe that this device has the potential to become the standard first-line tool for the management of completely buried bumpers.