Suspected malignant degeneration in a Zenker's diverticulum: should we biopsy it?

We report the case of an 89-year-old female who presented with progressive weight loss, oropharyngeal dysphagia and food regurgitation.

Pedunculated mucosa-associated lymphoid tissue (MALT) lymphoma causing gastric outlet obstruction.

An 86-year-old female presented with anemia and dyspepsia. She underwent esophagogastroduodenoscopy, which revealed a giant pedunculated polyp located in the gastric corpus, protruding into the duodenal bulb, causing gastric outlet obstruction (GOO). Thus, an endoscopic resection was scheduled.

A case of Currarino syndrome in an adult female presenting with refractory chronic constipation

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Implementation of a peroral endoscopic myotomy program.

INTRODUCTION: the aim of our study was to develop a peroral endoscopic myotomy (POEM) program in our Unit following a two-step sequence: training on animal models and supervision by an experienced endoscopist during the first human cases. METHODS: a single endoscopist experienced in advanced endoscopy was trained in POEM. After observing POEM in referral centers, training was implemented on swine models (preclinical phase). Technical aspects and adverse events were prospectively recorded. A first subset of cases (group A) was compared to a second one (group B) to assess our progression. Finally, POEM was implemented in humans under the supervision of an experienced endoscopist (clinical phase). The outcomes and adverse events were prospectively recorded. RESULTS: during the preclinical phase, 15 POEM procedures were performed on live pigs. Severe adverse events (AE) were less frequent in group B than in group A (12 % vs 57 %, p = 0.07). After nine cases, a plateau of adverse events was reached. During the clinical phase, eleven POEM procedures were performed in patients under expert supervision. Technical and clinical (Eckardt score ≤ 3) success were 100 % and 91 %, respectively (follow-up 3-21 months). In two cases, intervention of an experienced endoscopist was required (cases 2 and 3) because of a difficult orientation at the esophagogastric junction. One mild pneumoperitoneum occurred, with no severe adverse events reported. CONCLUSIONS: training in animal models and supervision by an experienced endoscopist during the first cases could provide the necessary skills to perform POEM safely and effectively.

A case of Currarino syndrome in an adult female presenting with refractory chronic constipation.

We present the case of a 25-year-old female who presented due to refractory chronic constipation and fecal incontinence. She had bowel movements every 7-30 days with an increased consistency (1-2 Bristol type stools), together with soiling and passive fecal incontinence (Wexner Scale: 12/20). She had previously undergone surgery shortly after birth for an anorectal malformation repair. The colonoscopy and histological study of the rectum were normal. A pelvic magnetic resonance imaging (MRI) was performed, which showed a right pararectal mass that compressed the rectum without invading it. This mass was compatible with a presacral teratoma or hamartoma. MRI also revealed coccyx agenesis and hypoplasia of the last sacral vertebrae (Image 1), which were consistent with Currarino syndrome (CS). The patient received 14 sessions of transcutaneous electrostimulation of the posterior tibial nerve, resulting in an increase in bowel movements (every 3 days) and a reduction in fecal incontinence. She was then referred to surgery for presacral mass removal.

Linfoma no Hodgkin folicular con afectación primaria cólica / No disponible

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Follicular non-Hodgkin lymphoma with primary colonic involvement.

We report the case of a 76-year-old female who underwent a colonoscopy for post-polypectomy follow-up. A nodular area was found in the proximal rectum that was suggestive of hyperplastic polyps by location and endoscopic appearance. Biopsies were taken due to its slightly atypical characteristics, with a final histological result of lymphoid aggregates.

Resección endoscópica mucosa en el tratamiento de la cap poliposis / No disponible

Cap-poliposis es un síndrome benigno poco frecuente caracterizado por la aparición de pólipos cólicos de aspecto inflamatorio cubiertos por un exudado fibrinopurulento. La diarrea mucosa y sangrado rectal son síntomas frecuentes. En ocasiones resulta difícil su diagnóstico y es necesario realizar el diagnóstico diferencial con otras entidades. Su patogenia es desconocida y su evolución variable. El tratamiento no está claramente establecido

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Endoscopic mucosal resection for cap poliposis treatment.

Cap-polyposis is a rare benign condition characterized by inflammatory colorectal polyps covered by a "cap" of fibrinopurulent exudate. Mucous diarrhea and rectal bleeding are frequent symtoms. It can be difficult to diagnose and it is necessary to make a differential diagnosis from other entities. Its pathogenesis is unknown and it has a variable clinical course. The optimal treatment has not been established.

Role of Endoscopy in the Management of Boerhaave Syndrome.

Boerhaave syndrome (BS) is a spontaneous esophageal perforation which carries high mortality. Surgical treatment is well established, but the development of interventional endoscopy has proposed new therapies. We expose our experience in a Gastrointestinal and Endoscopy Unit. With a retrospective, observational, open-label, single center, consecutive case series. All patients diagnosed with BS who were managed in our center were included. Treated conservatively, endoscopically or surgically, according to their clinical condition and lesion presentation. Fourteen patients were included. Ten were treated with primary surgery. One conservatively. In total, 7/14 patients required an endoscopic treatment. All required metallic stents deployment, 3 cases over-the-scope-clips concomitantly and one case a novel technique an internal drain. 6/7 cases endoscopically treated achieved complete esophageal healing. In conclusion, endoscopy is an useful tool at all stages BS management: difficult diagnosis, primary treatment in selected patients and as salvage when surgery fails. With mortality rates and outcomes comparables to surgery.

Per-oral endoscopic myotomy (POEM): a new endoscopic treatment for achalasia

Background/aims: Per-oral endoscopic myotomy (POEM) is a new minimally invasive technique to treat achalasia. Methods: We performed a review of the literature of POEM with a special focus on technical details and the results obtained with this technique in patients with achalasia and other esophageal motility disorders. Results: Thousands of POEM procedures have been performed worldwide since its introduction in 2008. The procedure is based on the creation of a mucosal entry point in the proximal esophagus to reach the cardia through a submucosal tunnel and then perform a myotomy of the muscular layers of the cardia, esophagogastric junction and distal esophagus, as performed in a Heller myotomy. The clinical remission rate ranges from 82 to 100%. Although no randomized studies exist and available data are from single-center studies, no differences have been found between laparoscopic Heller myotomy (LHM) and POEM in terms of perioperative outcomes, short-term outcomes (12 months) and long-term outcomes (up to three years). Procedure time and length of hospital stay were lower for POEM. Post-POEM reflux is a concern, and controversial data have been reported compared to LHM. The technique is safe, with no reported deaths related to the procedure and an adverse event rate comparable to surgery. Potential complications include bleeding, perforation, aspiration and insufflation-related adverse events. Thus, this is a complex technique that needs specific training even in expert hands. The indication for this procedure is widening and other motor hypercontractil esophageal disorders have been treated by POEM with promising results. POEM can be performed in complicated situations such as in pediatric patients, sigmoid achalasia or after failure of previous treatments. Conclusions: POEM is an effective treatment for achalasia and is a promising tool for other motor esophageal disorders. It is a safe procedure but, due to its technical difficulty and possible associated complications, the procedure should be performed in referral centers by trained endoscopists (AU)

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Per-oral endoscopic myotomy (POEM): a new endoscopic treatment for achalasia.

BACKGROUND/AIMS: Per-oral endoscopic myotomy (POEM) is a new minimally invasive technique to treat achalasia. METHODS: We performed a review of the literature of POEM with a special focus on technical details and the results obtained with this technique in patients with achalasia and other esophageal motility disorders. RESULTS: Thousands of POEM procedures have been performed worldwide since its introduction in 2008. The procedure is based on the creation of a mucosal entry point in the proximal esophagus to reach the cardia through a submucosal tunnel and then perform a myotomy of the muscular layers of the cardia, esophagogastric junction and distal esophagus, as performed in a Heller myotomy. The clinical remission rate ranges from 82 to 100%. Although no randomized studies exist and available data are from single-center studies, no differences have been found between laparoscopic Heller myotomy (LHM) and POEM in terms of perioperative outcomes, short-term outcomes (12 months) and long-term outcomes (up to three years). Procedure time and length of hospital stay were lower for POEM. Post-POEM reflux is a concern, and controversial data have been reported compared to LHM. The technique is safe, with no reported deaths related to the procedure and an adverse event rate comparable to surgery. Potential complications include bleeding, perforation, aspiration and insufflation-related adverse events. Thus, this is a complex technique that needs specific training even in expert hands. The indication for this procedure is widening and other motor hypercontractil esophageal disorders have been treated by POEM with promising results. POEM can be performed in complicated situations such as in pediatric patients, sigmoid achalasia or after failure of previous treatments. CONCLUSIONS: POEM is an effective treatment for achalasia and is a promising tool for other motor esophageal disorders. It is a safe procedure but, due to its technical difficulty and possible associated complications, the procedure should be performed in referral centers by trained endoscopists.

Erratum: Endoscopic esophagogastric anastomosis with luminal apposition Axios stent (LAS) approach: a new concept for hybrid "Lewis Santy".

[This corrects the article DOI: 10.1055/s-0043-106577.].

Correlation between serological biomarkers and endoscopic activity in patients with inflammatory bowel disease / Correlación entre los marcadores biológicos y la actividad endoscópica en pacientes con enfermedad inflamatoria intestinal

BACKGROUND/AIMS: Endoscopy is the gold standard for assessing disease severity in inflammatory bowel disease (IBD), although it is an invasive procedure. Biological markers have been routinely used as a non-invasive means of determining disease activity. The aim of this study was to determine the correlation between common biological markers and endoscopic activity in IBD. METHODS: Consecutive patients with IBD were included. Serum concentrations of different biomarkers (C-reactive protein [CRP], orosomucoid [ORM], erythrocyte sedimentation rate [ESR], fibrinogen, platelets, leukocytes, neutrophils and hemoglobin [Hb]) were measured, and their accuracy in detecting endoscopic activity was determined. RESULTS: Eighty patients were included (mean age 46 years, 53% Crohn's disease), 70% with endoscopic activity. Among Crohn's disease patients, 24% had mild endoscopic activity, 12% moderate activity and 39% severe activity. Among ulcerative colitis patients, 35% had an endoscopic Mayo score of 0-1 points, 30% 2 points and 35% 3 points. None of the biomarkers included had a good correlation with endoscopic activity (Area Under the ROC curve [AUC] < 0.70) in ulcerative colitis. ORM, fibrinogen and platelets had the best accuracy to detect endoscopic activity in Crohn's disease (AUC: 0.80-0.085). A sub-analysis in postoperative Crohn's disease patients found no correlation between endoscopic recurrence and biomarkers (AUC < 0.70). CONCLUSIONS: Serological biomarkers, including CRP, have low accuracy to detect endoscopic activity in ulcerative colitis and postoperative Crohn's disease. ORM, fibrinogen and platelets have the best accuracy to detect endoscopic activity in Crohn's disease

ANTECEDENTOS/OBJETIVOS: La endoscopia es el criterio de referencia para evaluar la severidad en la enfermedad inflamatoria intestinal (EII), aunque es un procedimiento invasivo. Se han utilizado rutinariamente marcadores biológicos como medios no invasivos para determinar la actividad de dicha enfermedad. El objetivo de este estudio fue el de determinar la correlación entre los marcadores biológicos comunes y la actividad endoscópica en la EII. MÉTODOS: Se incluyó a pacientes consecutivos con EII. Se midieron las concentraciones séricas de los diferentes marcadores (proteína C reactiva, proteína orosomucoide, índice de sedimentación de eritrocitos, fibrinógeno, plaquetas, leucocitos, neutrófilos y hemoglobina) y se determinó su precisión en la detección de la actividad endoscópica. RESULTADOS: Se incluyó a 80 pacientes (edad media de 46 años, el 53% con enfermedad de Crohn), el 70% de ellos con actividad endoscópica. Entre los pacientes con enfermedad de Crohn, el 24% tenía una actividad endoscópica leve, el 12% moderada y el 39% una actividad severa. Entre los pacientes con colitis ulcerosa, el 35% tenía un índice de Mayo de 0-1 puntos, el 30% de 2 puntos y el 35% de 3 puntos. Ninguno de los biomarcadores incluidos reflejó una buena correlación con la actividad endoscópica (área bajo la curva ROC < 0,70) en los casos de colitis ulcerosa. Los valores de proteína orosomucoide, fibrinógeno y plaquetas reflejaron la mejor fiabilidad para la detección de la actividad endoscópica en la enfermedad de Crohn (área bajo la curva ROC 0,80-0,085). Un subanálisis postoperatorio realizado a los pacientes con enfermedad de Crohn no reflejó relación alguna entre la recidiva endoscópica y los biomarcadores (área bajo la curva ROC < 0,70). CONCLUSIÓN: Los biomarcadores séricos, incluyendo la proteína C reactiva, son poco fidedignos en los casos de colitis ulcerosa y enfermedad de Crohn postoperatoria. Los valores de proteína orosomucoide, fibrinógeno y plaquetas son más precisos para la detección de la actividad endoscópica en la enfermedad de Crohn

EUS hepaticogastrostomy for bilioenteric anastomotic strictures: a permanent access for repeated ambulatory dilations? Results from a pilot study.

BACKGROUND AND STUDY AIMS: Postsurgical benign bilioenteric anastomotic strictures are a major adverse event of biliary surgery and endoscopic treatment, including endoscopic retrograde cholangiopancreatography (ERCP), is challenging in this setting. We present an innovative approach to treating this complication. PATIENTS AND METHODS: Patients underwent endoscopic ultrasound (EUS)-hepaticogastrostomy (HG) to treat nonmalignant biliary obstructions. A first endoscopy was performed to create the hepaticogastrostomy and to drain the biliary tree. The second step had a therapeutic purpose: antegrade dilation of the anastomosis. RESULTS: Four men and three women with benign bilioenteric anastomotic strictures were included. Patients presented with jaundice or recurrent cholangitis. A fully covered HG stent was successfully deployed during the first endoscopy. During the second step, repeat antegrade dilation was performed through the HG in four cases (1 - 4 dilations) followed by double pigtail stenting in three cases. In three other patients, the stenosis was not crossable and a double pigtail stent was placed to maintain biliary drainage. All patients had symptom relief at the end of follow-up (45 weeks, range 33 - 64). CONCLUSIONS: Dilation of anastomotic stenosis through a hepaticogastrostomy is feasible and may provide permanent biliary drainage or recurrent access to the biliary tree in patients with altered anatomy. Double pigtail stents might prevent migration.

Correlation between serological biomarkers and endoscopic activity in patients with inflammatory bowel disease.

BACKGROUND/AIMS: Endoscopy is the gold standard for assessing disease severity in inflammatory bowel disease (IBD), although it is an invasive procedure. Biological markers have been routinely used as a non-invasive means of determining disease activity. The aim of this study was to determine the correlation between common biological markers and endoscopic activity in IBD. METHODS: Consecutive patients with IBD were included. Serum concentrations of different biomarkers (C-reactive protein [CRP], orosomucoid [ORM], erythrocyte sedimentation rate [ESR], fibrinogen, platelets, leukocytes, neutrophils and hemoglobin [Hb]) were measured, and their accuracy in detecting endoscopic activity was determined. RESULTS: Eighty patients were included (mean age 46 years, 53% Crohn's disease), 70% with endoscopic activity. Among Crohn's disease patients, 24% had mild endoscopic activity, 12% moderate activity and 39% severe activity. Among ulcerative colitis patients, 35% had an endoscopic Mayo score of 0-1 points, 30% 2 points and 35% 3 points. None of the biomarkers included had a good correlation with endoscopic activity (Area Under the ROC curve [AUC]<0.70) in ulcerative colitis. ORM, fibrinogen and platelets had the best accuracy to detect endoscopic activity in Crohn's disease (AUC: 0.80-0.085). A sub-analysis in postoperative Crohn's disease patients found no correlation between endoscopic recurrence and biomarkers (AUC<0.70). CONCLUSION: Serological biomarkers, including CRP, have low accuracy to detect endoscopic activity in ulcerative colitis and postoperative Crohn's disease. ORM, fibrinogen and platelets have the best accuracy to detect endoscopic activity in Crohn's disease.