Underwater Endoscopic Mucosal Resection Vs Conventional Endoscopic Mucosal Resection for Superficial Nonampullary Duodenal Epithelial Tumors in the Western Setting.

BACKGROUND & AIMS: Conventional endoscopic mucosal resection (C-EMR) is established as the primary treatment modality for superficial nonampullary duodenal epithelial tumors (SNADETs), but recently underwater endoscopic mucosal resection (U-EMR) has emerged as a potential alternative. The majority of previous studies focused on Asian populations and small lesions (≤20 mm). We aimed to compare the efficacy and outcomes of U-EMR vs C-EMR for SNADETs in a Western setting. METHODS: This was a retrospective multinational study from 10 European centers that performed both C-EMR and U-EMR between January 2013 and July 2023. The main outcomes were the technical success, procedure-related adverse events (AEs), and the residual/recurrent adenoma (RRA) rate, evaluated on a per-lesion basis. We assessed the association between the type of endoscopic mucosal resection and the occurrence of AEs or RRAs using mixed-effects logistic regression models (propensity scores). Sensitivity analyses were performed for lesions ≤20 mm or >20 mm. RESULTS: A total of 290 SNADETs submitted to endoscopic resection during the study period met the inclusion criteria and were analyzed (C-EMR: n = 201, 69.3%; U-EMR: n = 89, 30.7%). The overall technical success rate was 95.5% and comparable between groups. In logistic regression models, compared with U-EMR, C-EMR was associated with a significantly higher frequency of overall delayed AEs (odds ratio [OR], 4.95; 95% CI, 2.87-8.53), postprocedural bleeding (OR, 7.92; 95% CI, 3.95-15.89), and RRAs (OR, 3.66; 95% CI, 2.49-5.37). Sensitivity analyses confirmed these results when solely considering either small (≤20 mm) or large (>20 mm) lesions. CONCLUSIONS: Compared with C-EMR, U-EMR was associated with a lower rate of overall AEs and RRAs, regardless of lesion size. Our results confirm the possible role of U-EMR as an effective and safe technique in the management of SNADETs.

Best Practices in Pancreatico-biliary Stenting and EUS-guided Drainage.

Indications for endoscopic placement of endoluminal and transluminal stents have greatly expanded over time. Endoscopic stent placement is now a well-established approach for the treatment of benign and malignant biliary and pancreatic diseases (ie, obstructive jaundice, intra-abdominal fluid collections, chronic pancreatitis etc.). Ongoing refinement of technical approaches and development of novel stents is increasing the applicability and success of pancreatico-biliary stenting. In this review, we discuss the important developments in the field of pancreatico-biliary stenting, with a specific focus on endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-associated developments.

Pneumatosis intestinalis: a rare endoscopic feature of colonic ischemia.

A 71-year-old male was admitted on intensive care unit after endovascular aneurysm repair of ruptured infrarenal abdominal aortic aneurysm. 2 weeks later, he had multiple episodes of bloody diarrhea. Colonoscopy revealed diffuse dusky mucosal coloration with loss of vasculature pattern, diseased haustrations, and diffuse areas of pneumatosis, suggestive of severe colonic ischemia.

Triple-sized intragastric balloon due to spontaneous hyperinflation.

A 38-year-old female with medical history of breast cancer, hypertension, diabetes mellitus and obesity (body max index 55kg/m2), was admitted to the emergency room with complains of nausea and vomits. Three weeks prior to the presentation, she placed an intragastric balloon (IGB) (Orbera365™, Apollo endosurgery Inc., Austin, TX), for weight loss, filled with 600ml solution of saline and methylene blue dye. Upon physical examination, she was dehydrated and presented with a bulging of the upper abdominal wall associated with mild abdominal pain. Laboratory tests showed severe metabolic alkalosis, hypocalcemia and hypokalemia. Abdominal x-ray revealed gastric distension with an increased size IGB, measuring 164.3*145.6*144.1 mm (estimated volume of 1800mL), with an air-fluid level. Upper endoscopy revealed the balloon stuck in the antrum. A catheter needle was used to puncture and deflate the balloon. Once deflated it was removed with endoscopic forceps. The fluid was not sent for microbiologic culture. After IGB removal, hydroelectrolytic disturbances were resolved and oral feeding was promptly resumed without further complications.

A rare case of monomorphic epitheliotropic intestinal T-cell lymphoma mimicking Crohn's disease.

A 70-years-old male was referred to us due to bloody diarrhea and involuntary weight loss during the last 2 months. Laboratory workup revealed anemia, hypoalbuminemia, and elevated reactive-C-protein. Computed tomography documented a wall thickening of sigmoid colon. Colonoscopy revealed pleomorphic ulceration of the sigmoid and descending colon. Aphthous ulcers were seen in ilium. Histology revealed mucosal infiltration with small sized atypical lymphoid cells in the epithelium and lamina propria, with extensive epitheliotropism.

Self-expandable metal stents in esophageal cancer before preoperative neoadjuvant therapy: efficacy, safety, and long-term outcomes.

BACKGROUND: Self-expandable metal stent (SEMS) placement for malignant dysphagia before preoperative neoadjuvant therapy (NT) is controversial. AIM: Evaluate SEMS placement impact on clinical and oncologic outcomes in patients with esophageal cancer who underwent surgery after NT. METHODS: Retrospective study of esophageal cancer patients referred for esophagectomy after NT. A propensity score was built consisting of the conditional probability of having had a SEMS given a set of baseline variables. In the SEMS group, patients underwent SEMS placement followed by NT and esophagectomy, whereas in the non-SEMS group, patients underwent only NT and esophagectomy. RESULTS: One hundred patients were included, 29 in the SEMS group and 71 in the non-SEMS group. Median follow-up was 18 months. SEMS-related adverse events occurred in 20.7% of the patients. After propensity score analysis, SEMS use decreased delta dysphagia score (regression coefficient [RC]: - 2.69, 95% CI - 3.18 to - 2.21), dysphagia grade before surgery (RC: - 0.74, 95% CI - 1.22 to - 0.27), hospital readmissions at 1 month (OR 0.18; p = 0.019), but increased overall morbidity after surgery (OR 3.02; p = 0.045). No significant differences were found regarding delta albumin levels and albumin levels before surgery, delta weight and weight before surgery, death related to surgery, number of lymph nodes harvested, R0 resection rate, tumor recurrence, recurrence-free survival, overall survival, and 30-day, 6-month, and 3-year mortality. CONCLUSION: SEMS placement improved dysphagia and allowed patients to maintain an equal nutritional status compared to patients without dysphagia during NT. Although postsurgical morbidity was higher in patients with SEMS placement, postsurgical mortality and oncological outcome were not different.

Two-devices-in-one-channel method: a challenging cannulation of intradiverticular major papilla.

Video 1Two-devices-in-one-channel method with a SpyGlass retrieval basket (Boston Scientific, Marlborough, Mass, USA) grabbing and pulling one of the previously placed through-the-scope clips and biliary cannulation with a conventional sphincterotome, using the double-guidewire technique.

Technical Review on Endoscopic Treatment Devices for Management of Upper Gastrointestinal Postsurgical Leaks.

Upper gastrointestinal postsurgical leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Nowadays, endoscopy is considered the first-line approach for their management, however, there is no definite consensus on the most appropriate therapeutic approach. There is a wide diversity of endoscopic options, from close-cover-divert approaches to active or passive internal drainage approaches. Theoretically, all these options can be used alone or with a multimodality approach, as each of them has different mechanisms of action. The approach to postsurgical leaks should always be tailored to each patient, taking into account the several variables that may influence the final outcome. In this review, we discuss the important developments in endoscopic devices for the treatment of postsurgical leaks. Our discussion specifically focuses on principles and mechanism of action, advantages and disadvantages of each technique, indications, clinical success, and adverse events. An algorithm for endoscopic approach is proposed.

Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review.

Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.

Clinicopathological characteristics and prognostic factors of small bowel lymphomas: a retrospective single-center study.

Background: There is little information on diagnosis and management of small bowel lymphomas, and optimal management strategies are still undefined. This study aims to describe their main clinical and pathological characteristics and identify poor prognostic factors. Methods: A retrospective observational study of all patients with histological diagnosis of small bowel lymphoma between January 2010 and December 2020 was performed. Results: We included 40 patients, with male predominance (60%) and mean age of 60.7 years. The ileum was the most common location, and the most common histological subtypes were follicular lymphoma and diffuse large B-cell lymphoma. Clinical presentation was variable from asymptomatic patients (30%) to acute surgical complications (35%) including perforation, intestinal obstruction, ileal intussusception, or severe bleeding. Diagnosis was established by endoscopy in 22 patients (55%), and the most common findings included polyps, single mass, diffuse infiltration, or ulceration, whereas 18 (45%) required surgery because of acute presentations or tumor resection, and lymphoma was diagnosed postoperatively. Surgery was curative in one-third of those patients. Median survival was 52 months. Acute presentation (P = 0.001), symptomatic disease (P = 0.003), advanced stage (P = 0.008), diffuse large B-cell lymphoma (P = 0.007), anemia (P = 0.006), hypoalbuminemia (P < 0.001), elevated lactate dehydrogenase (P = 0.02), elevated C-reactive protein (P < 0.001), and absence of treatment response (P < 0.001) were significant predictors of mortality. Conclusion: Small bowel lymphoma is a rare malignancy with diverse clinical and endoscopic presentations that require a high index of suspicion. Primary factors associated with worse outcome included acute presentation, advanced stage, histological subtype, biochemical abnormalities, and absence of treatment response.