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.

Are sarcopenia, frailty and malnutrition prognostic markers of liver disease decompensation in the ambulatory setting? - A prospective cohort study.

BACKGROUND: Sarcopenia, frailty and malnutrition are associated with adverse outcomes in liver cirrhosis. Studies assessing the prognostic value of these conditions in ambulatory patients with cirrhosis are scarce. METHODS: A prospective cohort study was conducted, with consecutive inclusion of all patients with cirrhosis observed in the Hepatology outpatient clinic of a Portuguese tertiary centre. At study enrolment, evaluation of muscle mass (ultrasound quadriceps femoris thickness), muscle strength (handgrip dynamometry) and nutritional status (Patient-Generated Subjective Global Assessment Short Form) was held. Follow-up ended upon the occurrence of a composite endpoint, comprising liver decompensation events and liver-related death, or last medical appointment/non-liver related death before the end of the study. The prognostic value of anthropometrical parameters and nutritional status in the composite endpoint was assessed using a multivariate Cox regression analysis, adjusted for several confounders. RESULTS: Ninety patients were enrolled (80% male), with a mean age of 63.5±10.5 years. The median follow-up was 30 (interquartile range 38) weeks, during which 12 patients reached the composite endpoint. These patients presented a lower mean handgrip strength [23.1±6.41 vs 30.3±10.4 Kg, p=0.04], compared to patients who did not reach the composite endpoint. On Cox regression multivariate analysis, however, no independent predictors of the composite endpoint were found, apart from previous decompensation episodes. CONCLUSION: In this study, muscle strength was lower in the group of patients with cirrhosis who presented a liver-related event. Handgrip strength might be a promising tool in the ambulatory setting to identify patients at risk of liver decompensation and liver-related death in the short term.

Effective submucosal tunneling endoscopic resection (STER) of a giant esophageal leiomyoma / Tunelización submucosa eficaz resección endoscópica (STER) de un esófago gigante leiomioma

We report the successful removal of a giant esophageal leiomyoma using submucosal tunneling endoscopic resection in a 37-year-old woman with significant dysphagia.(AU)

Effective submucosal tunneling endoscopic resection (STER) of a giant esophageal leiomyoma.

We report the successful removal of a giant esophageal leiomyoma using submucosal tunneling endoscopic resection in a 37-year-old woman with significant dysphagia.

Concordance of Dye-Spraying Chromoendoscopy and Virtual Chromoendoscopy for Colonic Dysplasia Detection in Longstanding Inflammatory Bowel Disease.

BACKGROUND/AIMS: In the past, dye-spraying chromoendoscopy was the technique of choice for colonic surveillance in patients with long-standing extensive inflammatory bowel disease. Recent evidence suggests that virtual chromoendoscopy is an equally acceptable technique. MATERIALS AND METHODS: Eleven gastroenterologists were given a survey with 20 pairs of pictures from inflammatory bowel disease surveillance colonoscopies (10 with nondysplastic lesions, 5 with dysplastic lesions, and 5 with no lesions). Each pair contained the same image captured during colonoscopy using indigo carmine and narrow-band imaging. For each picture, the gastroenterologist assessed the presence/absence of lesion and, when a lesion was identified, assessed the presence/absence of dysplasia and delineated its margins. To compare lesion and dysplasia detection between techniques, sensitivity, specificity, and interobserver agreement were calculated. The chi-square test was used to assess the accuracy of margins delineation. RESULTS: When assessing lesion and dysplasia detection, similar sensitivity and specificity values were obtained for both techniques. Interobserver agreement analysis revealed that dye-spraying chromoendoscopy and virtual chromoendoscopy had a moderate agreement in lesion detection but, for dysplasia detection, dye-spraying chromoendoscopy had a slight agreement [K = 0.11 (0.03-0.18), P < .01] and virtual chromoendoscopy a fair agreement [K = 0.30 (0.22-0.37), P < .01]. Margin delineation was similar between techniques. CONCLUSION: Sensitivity and specificity for lesion and dysplasia detection, as well as the accuracy of margins delineation, were similar between dye-spraying chromoendoscopy and virtual chromoendoscopy. Interobserver agreement for dysplasia detection was suboptimal in both techniques; however, it was superior when using virtual chromoendoscopy. These findings suggest that virtual chromoendoscopy constitutes a valid alternative for dysplasia screening in inflammatory bowel disease.

Tunneling-free peroral endoscopic septotomy for Zenker diverticulum.

Video 1Tunneling-free peroral endoscopic Zenker myotomy.

Endoscopic "purse-string" to close a rectal endoscopic submucosal dissection eschar with intentional muscular sectioning.

This case demonstrates the utility of the "purse string" to close large defects and shows that optical diagnosis may have pitfalls in evaluating the invasion of neoplastic lesions, particularly large ones.

Histological Inflammation in the Endoscopically Uninflamed Mucosa is Associated With Worse Outcomes in Limited Ulcerative Colitis.

BACKGROUND: The Montreal classification categorizes patients with ulcerative colitis (UC) based on their macroscopic disease extent. Independent of endoscopic extent, biopsies through all colonic segments should be retrieved during index colonoscopy. However, the prognostic value of histological inflammation at diagnosis in the inflamed and uninflamed regions of the colon has never been assessed. METHODS: This was a multicenter retrospective cohort study of newly diagnosed patients with treatment-naïve proctitis and left-sided UC. Biopsies from at least 2 colonic segments (endoscopically inflamed and uninflamed mucosa) were retrieved and reviewed by 2 pathologists. Histological features in the endoscopically inflamed and uninflamed mucosa were scored using the Nancy score. The primary outcomes were disease complications (proximal disease extension, need for hospitalization or colectomy) and higher therapeutic requirements (need for steroids or for therapy escalation). RESULTS: Overall, 93 treatment-naïve patients were included, with a median follow-up of 44 months (range, 2-329). The prevalence of any histological inflammation above the endoscopic margin was 71%. Proximal disease extension was more frequent in patients with histological inflammation in the endoscopically uninflamed mucosa at diagnosis (21.5% vs 3.4%, P = 0.04). Histological involvement above the endoscopic margin was the only predictor associated with an earlier need for therapy escalation (adjusted hazard ratio, 3.69; 95% confidence interval, 1.05-13.0); P = 0.04) and disease complications (adjusted hazard ratio, 4.79; 95% confidence interval, 1.10-20.9; P = 0.04). CONCLUSIONS: The presence of histological inflammation in the endoscopically uninflamed mucosa at the time of diagnosis was associated with worse outcomes in limited UC.

Does urgent balloon-assisted enteroscopy impact rebleeding and short-term mortality in overt obscure gastrointestinal bleeding?

BACKGROUND AND AIMS: The diagnostic yield (DY) and therapeutic yield (TY) of balloon-assisted enteroscopy (BAE) in overt obscure gastrointestinal bleeding (OGIB) is higher in the first 72 h. This study aimed to evaluate if this higher DY and TY after urgent BAE impacted the rebleeding rate, time to rebleed and short-term mortality. METHODS: Retrospective cohort-study, which consecutively included all patients submitted to BAE for overt OGIB, between 2010 and 2019. Patients were distributed in 2 groups: (1) Urgent BAE; (2) Non-urgent BAE. Rebleeding was defined as an Hb drop >2 g/dL, need for transfusional support or presence of melena/hematochezia. RESULTS: Fifty-four patients were included, of which 17 (31.5%) were submitted to BAE in the first 72 h. DY and TY of urgent BAE (DY 88.2%; n = 15; TY 94.1%; n = 16) was higher compared to non-urgent BAE (DY 59.5%; n = 22; TY 45.9%; n = 17) (DY p = .03) (TY p = .001). The rebleeding rate at 1, 2, and 5 years was 32.0%, 34.0%and 37.0%, respectively. Rebleeding was lower after urgent BAE (17.6%; n = 3) compared to non-urgent BAE (45.9%; n = 17) (p = .04). Rebleeding tended to occurr earlier in non-urgent BAE, being at 6-months (32.5%) and 36 months (41.3%) (p = .05). OGIB related 30-day mortality was 5.4% (n = 2) for non-urgent BAE and 0% for urgent BAE (p = .5). CONCLUSION: Urgent BAE might be associated with higher DY and TY with lower rebleeding and trend toward higher rebleeding-free time.

Endoscopic and histologic activity assessment considering disease extent and prediction of treatment failure in ulcerative colitis.

BACKGROUND AND AIMS: DUBLIN score allows evaluation of disease activity and extent in ulcerative colitis (UC). This study aimed to evaluate DUBLIN score as a predictor of therapeutic failure as well as to associate endoscopic and histological activity scores to assess their joint performance. METHODS: Retrospective cohort study, with consecutive inclusion of patients undergoing total colonoscopy with serial biopsies between 2016 and 2019. DUBLIN score (0-9) was calculated as the product of Mayo endoscopic score (MSe 0-3) by disease extent (E1-E3). Histological activity was evaluated through Nancy score (0-4). Activity scores were correlated with biomarkers, treatment failure (therapeutic escalation, hospitalization and/or colectomy) and clinical remission at 6 months (Mayo partial score ≤ 1). RESULTS: One-hundred and seven patients were included. In 38.3% (n = 41) there was evidence of endoscopic activity (MSe ≥ 2) and in 50.5% (n = 54) histological activity (Nancy ≥ 2). MSe and DUBLIN scores showed good correlation (r = 0.943; p < .001) and both were significantly higher in patients with histological activity (p < .001). Therapeutic failure occurred in 25.2% (n = 27). MSe, DUBLIN, and Nancy scores were significantly associated with therapeutic failure (p < .001). The areas under the (AUC) ROC curve were 0.74 (MSe; p < .001), 0.78 (DUBLIN; p < .001) and 0.84 (Nancy; p < .001). Joint evaluation of endoscopic and histological activity by combining DUBLIN and Nancy scores was associated with therapeutic failure with a significantly higher AUC of 0.84 (p < .001) compared to the Dublin score alone (p = .003). CONCLUSION: Mayo and DUBLIN endoscopic scores correlated with each other and with histological activity. The joint evaluation of endoscopic and histological activity allowed to predict with greater accuracy treatment failure.

Prediction of adenoma recurrence after piecemeal endoscopic mucosal resection: interobserver agreement and utilization of the Sydney EMR recurrence tool.

Background and aims: Piecemeal endoscopic mucosal resection (pEMR) allows resection of larger non-invasive colorectal lesions. Adenoma recurrence is an important limitation and occurs in ≤20%. The present study aimed to validate the Sydney EMR recurrence tool (SERT) score as a predictor of both endoscopic and histologic recurrence and evaluate interobserver agreement in adenoma recurrence based on endoscopic scar assessment, among nonexperts in EMR.Methods: Retrospective cohort and cross-sectional study, in which all patients submitted to pEMR in a tertiary care center in Portugal, between 2012 and 2018 were included. SERT-score was calculated for all lesions and compared with the SMSA (size, morphology, site, access) score already validated as a predictor of adenoma recurrence. Image based offline analysis was performed to evaluate adenoma recurrence prediction and assess the interobserver agreement within a heterogeneous group of participants, mostly composed by nonexperts in EMR.Results: There was a moderate positive correlation between the SERT and SMSA scores (p <.001; r = 0.61). SERT-score was significantly associated with endoscopic recurrence (p =.005) and histologic recurrence (p = .015). Endoscopic prediction of recurrence had high coefficient of agreement (k-0.806; p < .001).Conclusion: Histologic recurrence after pEMR can be predicted by SERT score and optical diagnosis of recurrent adenoma has high interobserver agreement between nonexperts in EMR.

ASGE high-risk criteria for choledocholithiasis - Are they applicable in cholecystectomized patients?

BACKGROUND AND AIMS: The guidelines by the American Society for Gastrointestinal Endoscopy (ASGE) suggest that in patients with gallbladder in situ, endoscopic retrograde cholangiopancreatography (ERCP) should be performed in the presence of high-risk criteria for choledocholithiasis, after biochemical tests and abdominal ultrasound. There are no specific recommendations for cholecystectomized patients. The aim of this study was to evaluate the applicability of ASGE criteria for ERCP in cholecystectomized patients with suspected choledocholithiasis. METHODS: We conducted a retrospective study that included patients with high-risk ASGE criteria for choledocholithiasis who underwent ERCP from 2013-2016. RESULTS: We included 327 patients in our analysis - 258 with gallbladder in situ (79%) and 69 with cholecystectomy (21%). We showed that the ASGE criteria true positive rate was similar between patients with and without cholecystectomy - the prevalence of choledocholithiasis on ERCP was 71% in cholecystectomized and 70% in non-cholecystectomized. In addition, both the presence and the diameter of the CBD stone were predictors of positive ERCP in both groups. In contrast, the diameter of the CBD was predictor of positive ERCP only in non-cholecystectomized patients. CONCLUSIONS: Although dilatation of the CBD was not a predictive factor for choledocholithiasis in cholecystectomized patients, the ASGE criteria true positive rate was similar to that of non-cholecystectomized patients.

High Efficacy of Repeating Colonoscopy by an Advanced Endoscopist after an Incomplete Colonoscopy.

BACKGROUND AND AIMS: This study aims to evaluate the role of an advanced endoscopist to study the entire colon after an incomplete colonoscopy. METHODS: All patients with an elective incomplete colonoscopy performed under deep sedation in our department between January 2010 and October 2016 were included. Patients with a colonic stenosis, an inadequate bowel preparation, or a colonoscopy performed without deep sedation were excluded. Included patients were followed up to evaluate if and what type of subsequent examinations (colonoscopy by an advanced endoscopist, single-balloon enteroscopy [SBE], and/or CT colonography) was performed to complete the study of the entire colon. Lesions found during these subsequent examinations were also recorded. RESULTS: Ninety-three patients had an incomplete colonoscopy, with no diagnosis of colorectal cancer (CRC) and a high-risk polyp rate of 5.4% (n = 5). Seventy-seven patients with incomplete colonoscopies underwent subsequent examinations, namely CT colonography in 45.5% (n = 35), colonoscopy by an advanced endoscopist in 53.2% (n = 41), and SBE in 13% (n = 10). In the 49 patients who performed either colonoscopy (n = 39) or SBE (n = 10) by an advanced endoscopist, the cecal intubation rate was 100%, and high-risk polyps were found in 26.5% (n = 13) and CRC in 4.1%. CT colonography revealed findings consistent with polyps and CRC in 22.9% (n = 8) and 2.9% (n = 1) of the cases, respectively. Colonoscopy was further repeated in 6 patients with suspected polyps in CT colonography, confirming the initial diagnosis in 5 patients. CONCLUSIONS: Colonoscopy by an advanced endoscopist achieved cecal intubation in all patients, representing a good choice after an incomplete colonoscopy.

INTRODUÇÃO/OBJETIVO: O presente estudo pretende aval-iar o papel de um endoscopista avançado no estudo do cólon após colonoscopia incompleta (CI). MATERIAL: In-cluíram-se todos os doentes com CI eletiva realizada por especialista, sob sedação profunda entre janeiro de 2010 e outubro de 2016. Excluíram-se doentes com estenose cólica, colonoscopia com preparação inadequada e/ou sem sedação. Avaliaram-se os exames subsequentes (colonoscopia por endoscopista avançado, enteroscopia assistida por monobalão [EAB] e colonografia virtual [CV]) realizados para completar o estudo do cólon e as lesões diagnosticadas. RESULTADOS: Incluíram-se 93 CI, que de-tetaram pólipos de alto risco em 5.4% (n = 5) e não iden-tificaram carcinoma colorretal (CCR). Realizou-se um segundo exame em 82.8% (n = 77) dos doentes, designada-mente, a CV, colonoscopia por endoscopista avançado e EAB em 45.5% (n = 35), 53.2% (n = 41) e 13% (n = 10), res-petivamente. Nos 49 doentes que realizaram colonosco-pia (n = 39) ou SBE (n = 10) por endoscopista avançado, a taxa de entubação cecal foi de 100%, detetando-se póli-pos de alto risco em 26.5% (n = 13) e CCR em 4.1%. Na CV observaram-se achados compatíveis com pólipos em 22.9% (n = 8) e CCR em 2.9% (n = 1) dos casos. A colo-noscopia foi subsequentemente realizada em 6 doentes com suspeita de pólipos na CV, confirmando-se o diag-nóstico em 5 doentes. CONCLUSÃO: A entubação cecal foi conseguida em todos os doentes submetidos a colo-noscopia realizada por endoscopista avançado repre-sentando uma boa opção no estudo subsequente do cólon após uma CI.

Evaluation of the Usefulness of Virtual Chromoendoscopy with Different Color Modes in the MiroCam® System for Characterization of Small Bowel Lesions.

BACKGROUND: Virtual chromoendoscopy (VC) in small bowel capsule endoscopy can improve the visualization and characterization of different small bowel lesions (SBLs). There are few studies of its usefulness in the Given® system, and there is no evidence yet of its utility in the MiroCam® system. AIM: The aim of this study was to evaluate whether VC can improve the characterization of SBLs with the MiroCam® system. METHODS: Twenty-two patients were selected, in which 100 elementary lesions were identified, including erosions (n = 45), ulcers (n = 17), and angioectasias (n = 38). For each lesion identified, images were captured without chromoendoscopy (normal image [NI]) and with chromoendoscopy modes 1 (color mode [CM] 1), 2 (CM2), and 3 (CM3). A score from 1 to 4 was assigned to each image, in which a better evaluation of the characteristics and limits of the lesion was classified in ascending order, where 1 is the worst and 4 the best evaluation. The scores of the various modes were compared with Kendall's tau-c coefficient. RESULTS: The average scores attributed to the photographs in NI, CM1, CM2, and CM3 were 3.83, 2.89, 1.85, and 1.43, respectively (tau-c = -0.75, p < 0.001). Evaluating the elementary lesions independently, the average scores for modes NI, CM1, CM2, and CM3 were 3.83, 2.92, 1.86, and 1.38 (tau-c = -0.77, p < 0.001) for erosions, respectively; 3.87, 2.96, 1.76, and 1.40 (tau-c = -0.80, p < 0.001) for ulcers, respectively; and 3.81, 2.82, 1.87, and 1.50 (tau-c = -0.71, p < 0.001) for angioectasias, respectively. CONCLUSIONS: VC using the CMs available in the MiroCam® system has not proven useful for a better assessment of any of the SBLs.

INTRODUÇÃO: A cromoendoscopia virtual na capsula endoscópica (CE) tem como principal intuito melhorar a visualização e caracterização de diferentes lesões do intestino delgado. Existem poucos estudos da sua utilidade no sistema Given®, não existindo contudo evidência da sua utilidade no sistema MiroCam®. Objetivos: Avaliar a utilidade da cromoendoscopia virtual na caracterização de lesões elementares do intestino delgado no sistema MiroCam®. MÉTODOS: Avaliados 22 doentes, nos quais foram identificadas 100 lesões elementares, nomeadamente erosões (n: 45), úlceras (n: 17) e angiectasias (n: 38). Para cada lesão identificada, foram captadas imagens sem cromoendoscopia (imagem normal), e com cromoendoscopia nos modos 1 (color mode 1), 2 (color mode 2) e 3 (color mode 3). Atribuída a cada imagem uma pontuação de 1 a 4, na qual uma melhor avaliação das características e limites da lesão se encontra classificada de forma crescente, sendo que 1 corresponde à pior e o 4 à melhor avaliação. As pontuações dos vários modos foram comparadas pelo coeficiente de correlação de Kendall tau-c. RESULTADOS: A pontuação média atribuida às fotografias nos modos imagem normal (NI), color mode 1 (CM1), color mode 2 (CM2) e color mode 3 (CM3) foi respectivamente 3.83, 2.89, 1.85 e 1.43 (tau-c = −0.75, p < 0.001). Avaliando as lesões elementares independentemente, os scores médios para os modos NI, CM1,CM2 e CM3 foram: 3.83, 2.92, 1.86, 1.38 (tau-c = −0.77, p < 0.001) para erosões; 3.87, 2.96, 1.76, 1.40 (tau-c = −0.80, p < 0.001) para úlceras; 3.81, 2.82, 1.87, 1.50 (tau-c = −0.71, p < 0.001) para angiectasias. CONCLUSÕES: A cromoendoscopia virtual não se revelou útil para uma melhor avaliação de qualquer uma das lesões elementares.