Prevalence of Endoscopically Curable Low-Risk Cancer Among Large (≥20 mm) Nonpedunculated Polyps in the Right Colon.

BACKGROUND AND AIMS: Endoscopic submucosal dissection is increasingly promoted for the treatment of all large nonpedunculated colorectal polyps (LNPCPs) to cure potential low-risk cancers (superficial submucosal invasion without additional high-risk histopathologic features). The effect of a universal en bloc strategy on oncologic outcomes for the treatment of LNPCPs in the right colon is unknown. We evaluated this in a large Western population. METHODS: A prospective cohort of patients referred for endoscopic resection (ER) of LNPCPs was analyzed. Patients found to have cancer after ER and those referred directly to surgery were included. The primary outcome was to determine the proportion of right colon LNPCPs with low-risk cancer. RESULTS: Over 180 months until June 2023, 3294 sporadic right colon LNPCPs in 2956 patients were referred for ER at 7 sites (median size 30 [interquartile range 15] mm). A total of 63 (2.1%) patients were referred directly to surgery, and cancer was proven in 56 (88.9%). A total of 2851 (96.4%) of 2956 LNPCPs underwent ER (median size 35 [interquartile range 20] mm), of which 75 (2.6%) were cancers. The overall prevalence of cancer in the right colon was 4.4% (n = 131 of 2956). Detailed histopathologic analysis was possible in 115 (88%) of 131 cancers (71 after ER, 44 direct to surgery). After excluding missing histopathologic data, 23 (0.78%) of 2940 sporadic right colon LNPCPs were low-risk cancers. CONCLUSIONS: The proportion of right colon LNPCPs referred for ER containing low-risk cancer amenable to endoscopic cure was <1%, in a large, multicenter Western cohort. A universal endoscopic submucosal dissection strategy for the management of right colon LNPCPs is unlikely to yield improved patient outcomes given the minimal impact on oncologic outcomes. CLINICALTRIALS: gov, Numbers: NCT01368289, NCT02000141.

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.

Desmoid Tumor after Sleeve Gastrectomy: Case Report and Literature Review.

Desmoid tumor is a rare mesenchymal neoplasm of unknown etiology. Despite rare, the diagnosis of desmoid tumors after bariatric surgery is increased over the last few years. We report a case of a 26-year-old male with complains of abdominal pain and postprandial fullness, diagnosed with a locally advanced large intra-abdominal mass (40 × 21 × 11.7 cm) centered in the mesentery, developed 3 years after sleeve gastrectomy. Percutaneous biopsy was suggestive of a mesenquimatous tumor and the patient underwent surgery. R0 surgical resection was achieved, despite intimal contact and common vascularization with a jejunal loop. Histopathology examination of the surgical specimen revealed fusiform to stellate cells with mild atypia, thin-walled vessels, and diffuse beta-catenin expression (negative for DOG-1, CD117, CD34, S100, desmin, and alpha-actin). The diagnosis of a desmoid tumor was made. The patient remained asymptomatic, and no recurrence occurred over a 4-year follow-up. With the increasing number of bariatric surgeries, owing to the alarming growing incidence of obesity and related conditions, it is expected that desmoid tumors reports will gradually increase over the next few years. Thus, both gastroenterologists and surgeons should be aware of the potential for desmoid tumor development shortly after surgery, to offer a prompt diagnosis and treatment.

O tumor desmóide é uma neoplasia mesenquimatosa rara de etiologia desconhecida. Apesar de raros, temos assistido a um aumento do número de diagnósticos, ao longo dos últimos anos, de tumores desmóides que se desenvolvem após cirurgia bariátrica. Descrevemos o caso de um homem de 26 anos com queixas de dor abdominal e enfartamento pós-prandial, diagnosticado com uma massa intra-abdominal centrada no mesentério (40 × 21 × 11.7 cm), localmente avançada, 3 anos após ter realizado gastrectomia vertical. Foi efetuada biópsia percutânea, cujo resultado foi sugestivo de tumor mesenquimatoso e o paciente foi referenciado para cirurgia. O doente foi submetido a cirurgia e o tumor foi passível de ressecção cirúrgica R0, apesar de contacto íntimo e vascularização comum com uma ansa jejunal. O exame anatomopatológico revelou células fusiformes a estreladas com atipia ligeira e vasos de parede fina, bem como expressão difusa de beta-catenina (na ausência de expressão de DOG-1, CD117, CD34, S100, desmina e alfa-actina), sendo compatível com o diagnóstico de um tumor desmóide. O doente permanece assintomático e sem evidência de recidiva ao longo de 4 anos de vigilância. Com o aumento do número de cirurgias bariátricas devido ao aumento alarmante da incidência de obesidade e condições relacionadas, espera-se que os diagnósticos de tumores desmóides aumentem nos próximos anos. Assim, tanto gastroenterologistas quanto cirurgiões devem estar alerta para o desenvolvimento desta entidade, de forma a oferecer um diagnóstico e tratamento adequado e atempado.

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.