Implementation of esophageal endoscopic submucosal dissection in Spain: Results from the nationwide registry. / Implementación de la disección endoscópica submucosa esofágica en España: resultados del registro nacional.

INTRODUCTION AND AIMS: The outcomes of endoscopic submucosal dissection (ESD) in the esophagus have not been assessed in our country. Our primary aim was to analyze the effectiveness and safety of the technique. MATERIAL AND METHODS: Analysis of the prospectively maintained national registry of ESD. We included all superficial esophageal lesions removed by ESD in 17 hospitals (20 endoscopists) between January 2016 and December 2021. Subepithelial lesions were excluded. The primary outcome was curative resection. We conducted a survival analysis and used logistic regression analysis to assess predictors of non-curative resection. RESULTS: A total of 102 ESD were performed on 96 patients. The technical success rate was 100% and the percentage of en-bloc resection was 98%. The percentage of R0 and curative resection was 77.5% (n=79; 95%CI: 68%-84%) and 63.7% (n=65; 95%CI: 54%-72%), respectively. The most frequent histology was Barrett-related neoplasia (n=55 [53.9%]). The main reason for non-curative resection was deep submucosal invasion (n=25). The centers with a lower volume of ESD obtained worse results in terms of curative resection. The rate of perforation, delayed bleeding and post-procedural stenosis were 5%, 5% and 15.7%, respectively. No patient died or required surgery due to an adverse effect. After a median follow-up of 14months, 20patients (20.8%) underwent surgery and/or chemoradiotherapy, and 9 patients died (mortality 9.4%). CONCLUSIONS: In Spain, esophageal ESD is curative in approximately two out of three patients, with an acceptable risk of adverse events.

Fecal occult blood and calprotectin testing to prioritize primary care patients for colonoscopy referral: The advantage study.

BACKGROUND: Colonoscopy is the gold standard for colorectal cancer (CRC) diagnosis and screening, but endoscopy services are usually overburdened. This study aims to investigate the usefulness of fecal hemoglobin (fHb) and calprotectin (FC) for the identification of patients with high probability of CRC who need urgent referral. METHODS: In a multicenter prospective study, we enrolled symptomatic patients referred from primary care for colonoscopy. Prior to bowel preparation, fHb and FC quantitative tests were performed. The diagnostic performance was estimated for each biomarker/combination. We built a multivariable predictive model based on logistic regression, translated to a nomogram and a risk calculator to assist clinicians in the decision-making process. RESULTS: The study included 1224 patients, of whom 69 (5.6%) had CRC. At the fHb cut-offs of >0 and 10 µg/g, the negative predictive values for CRC were 98.8% (95% confidence interval 97.8%-99.3%) and 98.6% (95%CI 97.7%-99.1%), and the sensitivities were 85.5% (95%CI 75.0%-92.8%) and 79.7% (95%CI 68.3%-88.4%), respectively. When we added the cut-off of 150 µg/g of FC to both fHb thresholds, the sensitivity of fecal tests improved. In the multivariate logistic regression model, the concentration of fHb was an independent predictor for CRC; age and gender were also independently associated with CRC. CONCLUSIONS: fHb and FC are useful as part of a triage tool to identify those symptomatic patients with high probability of CRC. This can be easily applied by physicians to prioritize high-risk patients for urgent colonoscopy.

Endoscopic Vacuum Therapy for Upper Gastrointestinal Leaks and Perforations: Analysis From a Multicenter Spanish Registry.

INTRODUCTION: Endoscopic vacuum therapy (EVT) is a novel technique for closing upper gastrointestinal (UGI) defects. Available literature includes single-center retrospective cohort studies with small sample sizes. Furthermore, evidence about factors associated with EVT failure is scarce. We aimed to assess the efficacy and safety of EVT for the resolution of UGI defects in a multicenter study and to investigate the factors associated with EVT failure and in-hospital mortality. METHODS: This is a prospective cohort study in which consecutive EVT procedures for the treatment of UGI defects from 19 Spanish hospitals were recorded in the national registry between November 2018 and March 2022. RESULTS: We included 102 patients: 89 with anastomotic leaks and 13 with perforations. Closure of the defect was achieved in 84 cases (82%). A total of 6 patients (5.9%) had adverse events related to the EVT. The in-hospital mortality rate was 12.7%. A total of 6 patients (5.9%) died because of EVT failure and 1 case (0.9%) due to a fatal adverse event. Time from diagnosis of the defect to initiation of EVT was the only independent predictor for EVT failure (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005). EVT failure (OR 24.5, 95% CI 4.5-133, P = 0.001) and development of pneumonia after EVT (OR 246.97, 95% CI 11.15-5,472.58, P = 0.0001) were independent predictors of in-hospital mortality. DISCUSSION: EVT is safe and effective in cases of anastomotic leak and perforations of the upper digestive tract. The early use of EVT improves the efficacy of this technique.

Gastric calcinosis ulcer in a renal transplanted patient.

A 53-year-old lady with dysfunctional renal transplant and post-surgical hypoparathyroidism with phosphocalcic metabolism impairment was admitted to hospital because of long-lasting epigastric pain and nausea. An esophagogastroduodenoscopy was performed, visualising a nodular lesion of 1 cm diameter with a depressed and ulcerated base. Microscopically the lesion was in relation with a metastatic calcinosis ulcer. Pantoprazole was initiated and serum phosphocalcic levels adjusted, achieving symptom remission. In the follow-up esophagogastroduodenoscopy, the lesion was healing with a fibrinous base and the histopathological report diagnosed superficial gastritis.

Hepatic subcapsular hematoma post-endoscopic retrograde cholangiopancreatography requiring embolization.

Endoscopic retrograde cholangiopancreatography (ERCP) placement of biliary stents is the procedure of choice for bile duct strictures. Complications of endoscopic retrograde cholangiopancreatography have a low incidence. Hepatic subcapsular hematoma is uncommon but potentially serious. It is caused by laceration of the bile duct with guidewire or biliary traction during the procedure. Initial management is conservative with supportive measures. In case of hemodynamic instability or superinfection, embolization of the affected branch or even surgery could be performed.

Colonoscopy - When quality matters.

Colonoscopy technical quality is a primary determinant of clinical outcome. Unfortunately, there is enough evidence available for significant variability in endoscopists' performance. An assessment of the factors determining these differences will be crucial for designing measures to ensure effectiveness and safety in these procedures.

Germline CDH1 G212E Missense Variant: Combining Clinical, In Vitro and In Vivo Strategies to Unravel Disease Burden.

E-cadherin, encoded by CDH1, is an essential molecule for epithelial homeostasis, whose loss or aberrant expression results in disturbed cell-cell adhesion, increased cell invasion and metastasis. Carriers of CDH1 germline mutations have a high risk of developing diffuse gastric cancer and lobular breast cancer, associated with the cancer syndrome Hereditary Diffuse Gastric Cancer (HDGC). The ubiquitous availability of cancer panels has led to the identification of an increasing amount of "incidental" CDH1 genetic variants that pose a serious clinical challenge. This has sparked intensive research aiming at an accurate classification of the variants and consequent validation of their clinical relevance. The present study addressed the significance of a novel CDH1 variant, G212E, identified in an unusually large pedigree displaying strong aggregation of diffuse gastric cancer. We undertook a comprehensive pipeline encompassing family data, in silico predictions, in vitro assays and in vivo strategies, which validated the deleterious phenotype induced by this genetic alteration. In particular, we demonstrated that the G212E variant affects the stability and localization, as well as the adhesive and anti-invasive functions of E-cadherin, triggering epithelial disruption and disorganization. Our findings illustrate the clinical implication of a complementary approach for effective variant categorization and patient management.

COVID-19: What's next? / COVID-19: ¿y ahora qué?

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Seguimiento a largo plazo tras disección submucosa endoscópica de lesiones colorrectales en una cohorte española / No disponible

INTRODUCCIÓN: la disección submucosa endoscópica (DSE) en colon es una técnica en expansión en países occidentales. Existen pocos estudios con seguimiento a largo plazo. OBJETIVO: analizar supervivencia libre de enfermedad a largo plazo tras DSE y comparar las tasas de recidiva en función de diferentes factores. MATERIAL Y MÉTODOS: cohorte prospectiva de pacientes con DSE planeada entre septiembre de 2008 y diciembre de 2015. Cuando no fue posible técnicamente completar DSE se realizó disección híbrida en bloque o fragmentada. Se analizó la tasa de recurrencia a cinco años mediante curvas de Kaplan-Meier y se compararon en función de diferentes factores usando test de log-rank. RESULTADOS: se incluyó una cohorte inicial de 89 pacientes en los que se consiguió seguimiento en 69. De los 69 pacientes, en 31 (45 %) se realizó DSE; en once (16 %), DSE híbrida; y en 27 (39 %), DSE híbrida fragmentada. La mediana de seguimiento fue de 27 meses. La supervivencia libre de enfermedad a cinco años fue del 81 %. La media de endoscopias para eliminar la recurrencia fueron dos (rango 1-7) y ninguna requirió cirugía. La tasa de recidiva fue significativamente menor tras DSE "en bloque" respecto a fragmentada (15 % vs. 27 %, p = 0,036) y en resecciones R0 respecto a R1 (0 % vs. 26 %, p = 0,034). Las resecciones con márgenes laterales negativos en lesiones resecadas en bloque presentaron menor tasa de recidiva respecto a aquellas con márgenes afectos/desconocidos, que no alcanzaron la significación estadística (0 % vs. 28 %, p = 0,09). CONCLUSIONES: en nuestro estudio, la supervivencia libre de enfermedad a cinco años fue del 81 % y ningún paciente requirió cirugía durante el seguimiento. Las resecciones fragmentadas y R1 se asociaron de forma significativa con mayor tasa de recurrencia

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Disección submucosa endoscópica en lesiones gástricas epiteliales: resultados a largo plazo en una cohorte española / No disponible

INTRODUCCIÓN: la disección submucosa endoscópica sobre lesiones gástricas (DSE-G) es una técnica que permite la resección de tumores gástricos precoces en bloque, con una tasa de curación similar a la cirugía y una morbimortalidad menor. OBJETIVO: analizar la supervivencia total, la supervivencia libre de enfermedad y la tasa de recidiva en pacientes sometidos a DSE-G en una cohorte española a lo largo de su evolución clínica. MATERIAL Y MÉTODOS: estudio observacional prospectivo. Inclusión de pacientes sometidos a DSE-G de 2008 a 2015, con seguimiento entre seis y 60 meses. Se analizó la recurrencia a cinco años mediante curvas de Kaplan-Meier y los resultados fueron comparados entre diferentes factores (en bloque vs. resección fragmentada, resecciones curativas R0 vs. margen lateral afecto ML+) usando test log-rank. RESULTADOS: se analizaron 35 pacientes sometidos a DSE-G, con una mediana de seguimiento de 33,62 meses. Se identificaron cuatro recidivas en este periodo (11,4%), tres de ellas tratadas mediante nueva DSE-G. La presencia de ML+ en la pieza histológica se relacionó con mayor tasa de recidiva local durante el seguimiento (p = 0,06). Las resecciones fragmentadas presentaron un mayor riesgo de recidiva pero sin detectarse diferencias estadísticamente significativas (p = 0,49). No se registraron fallecimientos por neoplasia gástrica ni gastrectomía por persistencia de enfermedad en este periodo. La tasa de supervivencia global en nuestra serie fue de 94,3%. CONCLUSIONES: la DSE-G realizada en nuestro medio permite una tasa elevada de curación a largo plazo evitando la cirugía. Estos resultados se asemejan a las series europeas publicadas y aún se encuentran lejos de las tasas de curación y recidiva de las cohortes asiáticas. Los casos de recidiva local pueden ser controlados mediante endoscopia

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Long-term follow-up after endoscopic submucosal dissection of colorectal lesions in a Spanish cohort.

INTRODUCTION: ESD in the colon is an increasingly important technique in Western countries. There are few studies that include long term follow-up. AIM: to analyze the long term recurrence free survival rate after ESD and to compare recurrence rates according to different variables. METHODS: this was a prospective observational study of patients with a planned ESD from September 2008 to December 2015. When it was not possible to achieve an ESD, hybrid ESD was performed, either en bloc or piecemeal. Kaplan-Meier survival curves were used to assess the five year local recurrence free survival rate and the recurrence rate. The results were compared according to different factors. RESULTS: of the 89 patients scheduled for ESD who were initially enrolled in the study, 69 were finally included for follow-up. ESD was performed in 31 (45%) patients, KAR in eleven (16%) and pKAR in 27 (39%). The median follow-up was 27 months (range 6-60). The five year disease free survival rate was 81%. The average number of endoscopies needed to eliminate recurrence was two (range 2-7) and no patient required surgery for this reason. The recurrence rate was significantly higher in piecemeal resections vs en bloc resections (27% vs 15%, p = 0.036) and R1 resections vs R0 resections (26% vs 0%, p = 0.034). The presence of affected or unknown lateral margins in en bloc resections without other poor prognosis factors had higher recurrence rates but the difference was not statistically significant (28% vs 0%, p = 0.09). CONCLUSIONS: in our study, the five year disease free survival rate was 81% and no patient required surgery during follow-up. Piecemeal and R1 resections had significantly higher recurrence rates, as well as LM involvement, although this was not statistically significant.

Endoscopic submucosal dissection for gastric epithelial lesions: long-term results in a Spanish cohort.

INTRODUCTION: endoscopic submucosal dissection for gastric lesions (ESD-G) is a technique that allows en-bloc resection of early gastric tumors, with a cure rate similar to that of surgery but lower morbidity and mortality rates. OBJECTIVE: to assess total survival, disease-free survival and relapse rate during the course of disease in a Spanish cohort of patients undergoing ESD-G. MATERIAL AND METHODS: this was a prospective observational study of patients undergoing ESD-G from 2008 to 2015, with a follow-up ranging from six to 60 months. Recurrence at five years was analyzed using Kaplan-Meier curves and the results were compared according to several factors using the log-rank test. These included en-bloc versus piecemeal resection and R0 curative resection versus resection with affected lateral margins (LM+). RESULTS: a total of 35 patients undergoing ESD-G were assessed, with a median follow-up of 33.62 months. Four relapses were identified (11.4%) during this period, of which three were managed with repeat ESD-G. A histological specimen with LM+ was associated with a higher local relapse rate during follow-up (p = 0.06). Piecemeal resections had a higher relapse risk, although no statistically significant differences were identified (p = 0.49). No deaths from gastric cancer occurred and no gastrectomies due to persistent disease were performed during this period. The overall survival rate in our series was 94.3%. CONCLUSIONS: ESD-G in our setting provides high long-term cure rates, while avoiding surgery. These results are similar to those reported by the European series and remain far removed from the cure and relapse rates obtained in Asian cohorts. Local relapse cases may be monitored with endoscopy.

Vigilancia tras resección de pólipos de colon y de cáncer colorrectal. Actualización 2018 / Endoscopic surveillance after colonic polyps and colorrectal cancer resection. 2018 update

La evidencia disponible para estratificar el riesgo de presentar un cáncer colorrectal metacrónico tras la extirpación de pólipos colorrectales y determinar los intervalos de vigilancia es limitada y se basa en estudios observacionales. No obstante, a la espera de nuevas evidencias, es necesario unificar los criterios del seguimiento endoscópico en nuestro medio. Por ello, desde las principales sociedades científicas involucradas en el manejo de estos pacientes, como son la Asociación Española de Gastroenterología, la Sociedad Española de Medicina Familiar y Comunitaria, la Sociedad Española de Endoscopia Digestiva y el Grupo de Cribado de Cáncer Colorrectal de la Sociedad Española de Epidemiología, se ha creado este documento de consenso, que se encuentra incluido en el capítulo 10 de la «Guía de Práctica Clínica de Diagnóstico y Prevención del Cáncer Colorrectal. Actualización 2018». A continuación, se presentarán importantes novedades respecto a la edición previa publicada en 2009. En primer lugar, se establecen situaciones que requieren y no requieren vigilancia endoscópica y se elimina la necesidad de realizar seguimiento en individuos que no presentan un riesgo especial de cáncer de colon metacrono. En segundo lugar, se establecen recomendaciones de vigilancia endoscópica en individuos con pólipos serrados. Finalmente, a diferencia de la edición anterior, se dan recomendaciones de vigilancia endoscópica en individuos intervenidos por cáncer colorrectal. Paralelamente, supone un avance sobre la guía europea de calidad en el cribado del cáncer colorrectal, ya que elimina la división entre grupo de riesgo medio y grupo de riesgo alto, lo que supone la eliminación de una proporción considerable de colonoscopias de vigilancia precoz. Finalmente, se dan recomendaciones claras sobre la ausencia de necesidad de seguimiento en el grupo de riesgo bajo, para el que la guía europea mantenía cierta ambigüedad

There is limited scientific evidence available to stratify the risk of developing metachronous colorectal cancer after resection of colonic polyps and to determine surveillance intervals and is mostly based on observational studies. However, while awaiting further evidence, the criteria of endoscopic follow-up needs to be unified in our setting. Therefore, the Spanish Association of Gastroenterology, the Spanish Society of Family and Community Medicine, the Spanish Society of Digestive Endoscopy, and the Colorectal Cancer Screening Group of the Spanish Society of Epidemiology, have written this consensus document, which is included in chapter 10 of the "Clinical Practice Guideline for Diagnosis and Prevention of Colorectal Cancer. 2018 Update". Important developments will also be presented as regards the previous edition published in 2009. First of all, situations that require and do not require endoscopic surveillance are established, and the need of endoscopic surveillance of individuals who do not present a special risk of metachronous colon cancer is eliminated. Secondly, endoscopic surveillance recommendations are established in individuals with serrated polyps. Finally, unlike the previous edition, endoscopic surveillance recommendations are given in patients operated on for colorectal cancer. At the same time, it represents an advance on the European guideline for quality assurance in colorectal cancer screening, since it eliminates the division between intermediate risk group and high risk group, which means the elimination of a considerable proportion of colonoscopies of early surveillance. Finally, clear recommendations are given on the absence of need for follow-up in the low risk group, for which the European guidelines maintained some ambiguity

Endoscopic surveillance after colonic polyps and colorrectal cancer resection. 2018 update. / Vigilancia tras resección de pólipos de colon y de cáncer colorrectal. Actualización 2018.

There is limited scientific evidence available to stratify the risk of developing metachronous colorectal cancer after resection of colonic polyps and to determine surveillance intervals and is mostly based on observational studies. However, while awaiting further evidence, the criteria of endoscopic follow-up needs to be unified in our setting. Therefore, the Spanish Association of Gastroenterology, the Spanish Society of Family and Community Medicine, the Spanish Society of Digestive Endoscopy, and the Colorectal Cancer Screening Group of the Spanish Society of Epidemiology, have written this consensus document, which is included in chapter 10 of the "Clinical Practice Guideline for Diagnosis and Prevention of Colorectal Cancer. 2018 Update". Important developments will also be presented as regards the previous edition published in 2009. First of all, situations that require and do not require endoscopic surveillance are established, and the need of endoscopic surveillance of individuals who do not present a special risk of metachronous colon cancer is eliminated. Secondly, endoscopic surveillance recommendations are established in individuals with serrated polyps. Finally, unlike the previous edition, endoscopic surveillance recommendations are given in patients operated on for colorectal cancer. At the same time, it represents an advance on the European guideline for quality assurance in colorectal cancer screening, since it eliminates the division between intermediate risk group and high risk group, which means the elimination of a considerable proportion of colonoscopies of early surveillance. Finally, clear recommendations are given on the absence of need for follow-up in the low risk group, for which the European guidelines maintained some ambiguity.

Cribado del cáncer colorrectal y supervivencia / Colorectal cancer screening and surviva

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Switching from endoscopic submucosal dissection to salvage piecemeal knife-assisted snare resection to remove a lesion: a preoperative risk score from the beginning

Background and aims: endoscopic submucosal dissection (ESD) in the Western setting remains a challenge. Therefore, other simplified techniques such as knife-assisted snare resection (KAR) have been reported to overcome this issue. Methods: patients who underwent an ESD for the treatment of gastrointestinal neoplasms were included in a retrospective cross-sectional observational study. Factors associated with the end of ESD as a salvage p-KAR were identified and a logistic regression model was developed. Results: a total of 136 lesions in 133 patients were analyzed. Operator experience of under 50 cases and the combination of lesion size > 30 mm and colorectal location were independent predictive factors for switching to a salvage p-KAR according to the multivariate logistic regression analysis. We developed a risk scoring system based on these four variables (experience, size, location and the combination of size and location) with a receiver operating characteristic curve of 0.81 (95% CI: 0.74-0.89). The diagnostic accuracy of the score for a cut-off point ≥ 5 had a sensitivity of 0.79 (95% CI: 0.66-0.93) and a specificity of 0.71 (95% CI: 0.61-0.80). Conclusion: a simple predictive score system that includes four preoperative factors accurately predicts ESD to finish as a p-KAR. A careful selection of cases considering these variables could be useful to achieve better outcomes in the Western setting

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Colorectal cancer screening and survival.

It is difficult to resist the undeniable allure of screening as a means to diagnose common, potentially serious diseases before their natural history reaches an incurable stage. Colorectal cancer (CRC) is a classical example where the benefits seem to be within reach: we have technologies available that allow its diagnosis before symptoms or signs develop, at a reasonable cost, and using methods acceptable by a significant percentage of the population.