Endoscopic therapy for Bouveret syndrome, illustrated by a case report.

Bouveret syndrome is an exceptionally rare form of gallstone ileus secondary to a bilioenteric fistula, through which a voluminous gallstone can migrate into the pylorus or duodenum, thereby causing gastric outlet obstruction. In order to increase awareness, we reviewed the clinical features, diagnostic tools and management options for this uncommon entity. We specifically focus on endoscopic therapeutic options, illustrated by a case of a 73 year old woman with Bouveret syndrome, where endoscopic electrohydraulic lithotripsy was successful in relieving gastroduodenal obstruction.

Endoscopic management of buried bumper syndrome using the Balloon Dilation Pull (BDP) technique: a multicenter analysis.

Background and study aims: Buried bumper syndrome (BBS) may complicate percutaneous endoscopic gastrostomy placement. In these patients, endoscopic treatment ought to be considered. Various approaches have been published, ranging from dissectionbased techniques to novel dedicated devices, although the evidence supporting the use of the Balloon Dilation Pull (BDP) technique has been limited to single case reports. The aim of this paper is to assess the feasibility, efficacy and safety of the systematic use of the BDPtechnique for the endoscopic treatment of BBS. Patients and methods: We performed a retrospective multicenter analysis of prospectively collected data from all patients treated with the BDP-technique between January 2011 and November 2021. Results: In total, 26 patients were identified (median age 72 (SD ± 13) years, 74% male, 84.6% underlying neurological disease). Technical success was achieved in 92.3%, with a median procedure time of 17.5 minutes (range 5-27). Adverse events were identified in 3.8% of patients (N=1, aspiration, ASGE lexicon severity grade: moderate). Conclusions: Our experience suggests that the BDP-technique is highly efficacious and safe, using accessories readily available in every endoscopic unit. Given the limited procedure time and tools required, this procedure has the potential to further optimize patient care in the context of BBS.

Colorectal endoscopic submucosal dissection: a review on patient selection and indications.

Background: The development of 'third-space'-endoscopy has paved the way towards en-bloc resection of early gastrointestinal neoplasia. Endoscopic submucosal dissection (ESD) has improved the endoscopic management of colorectal lesions by facilitating R0-resection, improving histological assessment and preventing recurrence. Methods: The purpose of this review is to provide an evidence-based overview of indications for which ESD should be considered within colorectal endoscopy. Results: The development of ESD has partially bridged the gap between endoscopy and surgery, but depends heavily on adequate pre-resection visual evaluation, ruling out potential deep submucosal invasion. ESD should be considered for large colorectal polyps (≥20mm) and/or lesions diagnosed as harbouring high-grade dysplasia, in-situ carcinoma or superficial submucosal invasion. Not only has it found its way into our guidelines for the treatment of neuroendocrine neoplasms, ESD also seems a promising alternative for the controlled resection of large pedunculated lesions. ESD can also be applied in more challenging situations, such as in pre-treated lesions, post-surgical context and in patients with IBD, although this requires a high level of skill and expertise. Conclusions: In this review we have described the different indications for ESD and attempted to define its place within our current endoscopic armamentarium. For both non-expert and expert endoscopists, knowledge about ESD indications, patient selection and therapeutic alternatives, remains crucial in the care for patients with colorectal neoplasia.

Umbilical hernia repair in patients with cirrhosis: who, when and how to treat.

PURPOSE: Hernia management in patients with cirrhosis is a challenging problem, where indication, timing and type of surgery have been a subject of debate. Given the high risk of morbidity and mortality following surgery, together with increased risk of recurrence, a wait and see approach was often advocated in the past. METHODS: The purpose of this review was to provide an overview of crucial elements in the treatment of patients with cirrhosis and umbilical hernia. RESULTS: Perioperative ascites control is regarded as the major factor in timing of hernia repair and is considered the most important factor governing outcome. This can be accomplished by either medical treatment, ascites drainage prior to surgery or reduction of portal hypertension by means of a transjugular intrahepatic portosystemic shunt (TIPS). The high incidence of perioperative complications and inferior outcomes of emergency surgery strongly favor elective surgery, instead of a "wait and see" approach, allowing for adequate patient selection, scheduled timing of elective surgery and dedicated perioperative care. The Child-Pugh-Turcotte and MELD score remain strong prognostic parameters and furthermore aid in identifying patients who fulfill criteria for liver transplantation. Such patients should be evaluated for early listing as potential candidates for transplantation and simultaneous hernia repair, especially in case of umbilical vein recanalization and uncontrolled refractory preoperative ascites. Considering surgical techniques, low-quality evidence suggests mesh implantation might reduce hernia recurrence without dramatically increasing morbidity, at least in elective circumstances. CONCLUSION: Preventing emergency surgery and optimizing perioperative care are crucial factors in reducing morbidity and mortality in patients with umbilical hernia and cirrhosis.

Another gastrointestinal lesion amendable for ablation.

A 79-year-old patient, with a history of redoendoscopic ampullectomy (low grade dysplasia), was referred to our hospital with cholestatic liver function abnormalities and dilation of the common bile duct. Diagnostic endoscopic ultrasound (EUS) was performed (Figure 1, left), as well as upper gastrointestinal endoscopy (Figure 1, right). What is the final diagnosis and which treatment would you propose?

Clinical presentation, treatment modalities and outcome in patients with adrenocortical carcinoma: A single center experience.

Adrenocortical carcinoma is an orphan disease usually associated with a poor prognosis. Surgery is the only treatment with a curative intent, leaving systemic therapy mainly for the purpose of symptom control. First line combination chemotherapy with Etoposide, Doxorubicin, Cisplatin and Mitotane (EDP-Mitotane) is considered the standard of care, although this regimen is not associated with an overall survival benefit. Due to the rarity of the disease no standard therapy exists in the second line or when patients are intolerant to the first line treatment. Therefore, treatment of these patients is usually following a very individual path in daily practice. Our aim was to retrospectively analyze treatment of patients with adrenocortical carcinoma in our tertiary center and compare treatment outcomes with reports in the literature. Our findings reflect the daily practice in adrenocortical carcinoma treatment and showed that surgery is the mainstay of therapy, even in some cases with metastatic disease. Adjuvant therapy in adrenocortical carcinoma was initiated less frequently than suggested by current guidelines. Furthermore, most of the patients in our cohort received more than one line of chemotherapy for metastatic or inoperable disease with overall survival rates comparable to those published. In summary, our analysis stresses the importance of clinical trial activity in this rare disease in order to standardize and improve adrenocortical carcinoma therapy more profoundly.

A case of amoebic colitis with amoeboma and simultaneous liver abscesses. A diagnosis by colonoscopy.

A 50-year-old patient was admitted to our department after developing severe abdominal cramps, watery diarrhea and fever, during four days whilst travelling abroad. Imaging identified a mass in the ascending colon with simultaneous liver lesions. Initially a diagnosis of metastatic colorectal cancer was suggested, however colonoscopy showed a large lesion with a central ulcer and surrounding inflammation in the ascending colon. Biopsies confirmed our clinical suspicion of amoebic colitis, complicated by development of an amoeboma and simultaneous liver abscesses. Amoeboma formation is a rare complication of amoebiasis, however a simultaneous presentation with liver abscesses, amoebic colitis and an amoeboma might even be less frequent. Despite its rarity physicians should maintain a high index of suspicion of patients presenting with synchronous liver and colon lesions, especially as travel to endemic areas has increased.