Tomas Hucl

Úvod: Endoskopická full-thickness resekce (EFTR) představuje moderní miniinvazivní metodu určenou k léčbě lézí gastrointestinálního traktu nevhodných pro konvenční endoskopické resekční techniky. Nejčastější indikací jsou non-lifting adenomy, reziduální nebo recidivující neoplazie po předchozí endoskopické léčbě, časné kolorektální karcinomy a vybrané subepiteliální léze. Cílem studie bylo zhodnotit technickou úspěšnost, radikalitu resekce a bezpečnost metody EFTR pomocí systému Full-Thickness Resection Device (FTRD) na jednom terciárním pracovišti. Metody: Do retrospektivní monocentrické studie byli zařazeni všichni pacienti, kteří podstoupili endoskopickou full-thickness resekci pomocí systému FTRD na Klinice hepatogastroenterologie IKEM v období od října 2016 do května 2026. Hodnoceny byly demografické údaje, indikace k výkonu, charakteristika lézí, technická úspěšnost, histopatologické výsledky, četnost komplikací a výsledky kontrolních endoskopií. Výsledky: Celkem bylo provedeno 127 výkonů u 123 pacientů (75 mužů, 48 žen) s průměrným věkem 67,8 roku. Průměrná velikost lézí činila 14,2 ± 5,8 mm. Technická úspěšnost byla dosažena ve 113 případech (89,0 %). Histologicky kompletní (R0) resekce byla potvrzena v 85 případech (66,9 %), u karcinomů ve 26 z 39 případů (66,7 %). Komplikace byly zaznamenány u 16 výkonů (12,6 %), nejčastěji krvácení (7,9 %). Dvě perforace vyžadovaly chirurgickou revizi, jedna byla ošetřena pomocí OTSC. Kontrolní koloskopie byla dostupná u 79 výkonů, přičemž lokální reziduum bylo zjištěno v osmi případech (10,1 %). Závěr: Endoskopická full-thickness resekce pomocí systému FTRD představuje bezpečnou a účinnou metodu léčby obtížně resekovatelných či vhodných subepitelialních lézí gastrointestinálního traktu. Výsledky našeho souboru jsou srovnatelné s ostatními publikovanými daty a potvrzují význam této metody v současné terapeutické endoskopii.

Úvod: Kongenitální extrahepatální portosystémový shunt (CEPS; Abernethyho malformace) může být komplikován rozvojem jaterní encefalopatie, plicní hypertenze nebo hepatocelulárního karcinomu (HCC). Prezentujeme případy dvou pacientů s mnohočetným HCC a současným CEPS. Popis případů: Dívka, 17 let, s mohutným portokaválním shuntem byla odeslaná na naše pracoviště pro progredující mnohočetná ložiska jater charakteru FNH/ adenomů dle MR. Cílená bio­psie jednoho z ložisek prokázala hepatocelulární adenom s rizikovými histologickými znaky, nález byl chirurgicky neřešitelný a pacientka byla indikována k transplantaci jater (LT). V průběhu nekomplikované LT byl zrušen portokavální shunt. V explantátu jater byly přítomny mnohočetné adenomy jater, ně­kte­ré již s transformací do dobře diferencovaného HCC. Pacientka je 2,5 roku po LT s dobrou funkcí štěpu, bez recidivy HCC. Muž, 62 let, s mohutným portosystémovým shuntem mezi vena mesenterica superior a vena cava inferior a anamnézou jedné epizody jaterní encefalopatie byl odeslán na naše pracoviště pro CT nález dvou ložisek jater charakteru HCC v terénu pokročilé fibrózy jater (F3 dle elastografie). MR prokázala celkem šest ložisek jater velikosti do 25 mm charakteru HCC, AFP bylo 496 µg/ l. Nález překračoval indikační kritéria IKEM k LT pro HCC a pacient byl indikován k onkologické terapii. Závěr: Abernethyho malformace je spojena se zvýšeným rizikem rozvoje benigních (adenomy) a maligních tumorů (HCC) jater, pečlivá surveillance pacientů je nezbytná.

EUS-guided gastroenterostomy (EUS-GE) is becoming widely used to treat gastric outlet obstruction as an alternative to luminal stenting or laparoscopic surgery [11]. However, the procedure requires high technical skills and experience in order to prevent, recognize, and manage procedure-related adverse events. In this video, Shah et al. report a case of interposed colon between the stomach and the jejunal loop. The presence of the interfering colon with all its typical EUS features was obvious only when the tip of the scope was released, demonstrating the importance of this maneuver during EUS-GE. Inadvertent gastrocolostomy is a rare complication of EUS-GE, reported in 0.4%–2.4% of patients [22] [33]. This case further demonstrates not only that procedure cessation may prevent a severe adverse event possibly requiring surgery, but also that a repeated procedure a couple of days later may be successful in this setting. Article published online: 29 May 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Background Endoluminal radiofrequency ablation (RFA) has been promoted as palliative treatment for patients with cholangiocarcinoma (CCA) and pancreatic ductal adenocarcinoma (PDAC) in order to improve biliary drainage and eventually prolong survival. No high level evidence is, however, available on this technique. Design In this randomised controlled study, we compared endoluminal RFA plus stenting with stenting alone (control group) in patients with malignant biliary obstruction; metal stents were primarily placed. Primary outcome was overall survival; secondary outcomes were stent patency, quality of life and adverse events. In a superiority design, survival was assumed to be doubled by RFA as compared with 6.4 months in the control group (n=280). Results A total of 161 patients (male:female 90:71, mean age 71±9 years) were randomised before recruitment was terminated for futility after an interim analysis. Eighty-five patients had CCA (73 hilar, 12 distal) and 76 had pancreatic cancer. There was no difference in survival in both subgroups: for patients with CCA, median survival was 10.5 months (95% CI 6.7 to 18.3) in the RFA group vs 10.6 months (95% CI 9.0 to 24.8), p=0.58)) in the control group. In the subgroup with pancreatic cancer, median survival was 6.4 months (95% CI 4.3 to 9.7) for the RFA vs 7.7 months (95% CI 5.6 to 11.3), p=0.73) for the control group. No benefit was seen in the RFA group with regard to stent patency (at 12 months 40% vs 36% in CCA and 66% vs 65% in PDAC), and quality of life was unchanged by either treatment and comparable between the groups. Adverse events occurred in seven patients in each groups. Conclusion A combination of endoluminal RFA and stenting was not superior to stenting alone in prolonging survival or improving stent patency in patients with malignant biliary obstruction. Trial registration number NCT03166436.

Text 69-year-old patient with a history of right hepatectomy with hepaticojejunostomy for cholangio-carcinoma and PTD for jaundice for cancer recurrence presented at our department with vomiting and epigastric pain. Gastroscopy revealed a tight but passable stricture of the duodenal bulb, presumably due to tumorous infiltration of the surrounding tissue. Pneumatic dilation did not relieve symptoms and the patient was indicated for EUS-guided GE. Contrast visualization of the small bowel showed dislocation of the jejunal loop in the right upper abdominal quadrant, making it inaccessible for anastomosis. For this reason, LAMS has been placed between antrum and the descending part of the duodenum with both technical and clinical success. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Aims Endoluminal radiofrequency ablation (RFA) has been suggested a promising treatment modality for palliative treatment of cholangiocarcinoma (CCC) and pancreatic cancer (PC). Methods In a randomized controlled manner, we compared endoluminal radiofrequency ablation plus stenting with stenting alone in patients with malignant biliary obstruction with survival as the primary outcome and stent patency as the secondary outcome. Results A total of 161 patients with malignant biliary obstruction (85 with CCC and 76 with PC) were randomized [81 RFA + stent (44 CCC, 37 PC), 80 stent (41 CCC, 39 PC)]. The recruitment was terminated for futility after an interim analysis before enrolling the originally planned 280 patients. There was no difference in survival in patients with cholangiocarcinoma (median survival 10.5 months (95%CI 6.7-18.3) vs. 10.6 months (95%CI 9.0-24.8) and pancreatic cancer (median survival 6.4 months (95%CI 4.3-9.7) vs. 5.6 months (95% CI 5.6-11.3). Furthermore, no benefit was seen in stent patency in both CCC patients and PC patients. Complications occurred in 7 patients (8.6%) treated with RFA and 7 patients (8.8%) treated with stenting only (NS) ([Table 1]). Conclusions In malignant biliary obstruction, endoluminal radiofrequency ablation in addition to stenting was not superior to stenting alone in prolonging survival or stent patency. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Aims The aim of the study was to examine the prophylactic effect of internal biliary stents on the incidence of biliary complications, graft loss and overall mortality. Furthermore, the risk factors of biliary complications were studied Methods We performed a large-volume single-center study including all adult patients who underwent a deceased-donor liver transplantation either with end-to-end choledococholedocostomy or hepaticojejunostomy between 2005-2021 ([Fig. 1]). Results Out of 1447 liver transplant recipients (1555 liver transplantations), 456 (29%) patients had the size of the recipient or donor duct smaller < 6mm, making them eligible for biliary stenting. The incidence of biliary complications between the patients with and without internal biliary stents was comparable (24% vs. 23%, p= 0,7). Five, ten and fifteen-year graft survival rates were significantly lower among patients with biliary complications regardless of the presence of biliary stents (p<0.01), whereas patient long term survival did not differ between the groups. In multivariate analysis, thrombosis of the hepatic artery was the only risk factor for all types of biliary complications (p< 0,001). The relative number of biliary interventions was significantly higher in patients with biliary stents (p< 0,001). Conclusions Biliary stenting in liver transplant recipients with a narrow bile duct resulted in a similar incidence of biliary complications when compared to recipients with a normal duct and no stents, suggesting its protective role. During a long-term follow-up, graft loss was significantly higher among patients with biliary complications regardless of the presence of internal biliary stents, whereas mortality was comparable. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Endoscopic ultrasound (EUS)-guided drainage has been suggested as the treatment of choice for acute cholecystitis in high risk surgical patients, offering improved outcomes that include fewer re-interventions [1]. Gangrenous cholecystitis is a severe form of cholecystitis typically treated by surgery [2]. In this E-Video, Orlandini et al. report on a case where acute cholecystitis as yet unrecognized as gangrenous was successfully treated by EUS-guided drainage using a 10 × 10-mm lumen-apposing metal stent (LAMS). However, re-intervention was needed 3 weeks later because of stent occlusion by necrotic tissue. The presence of the LAMS allowed for complete endoscopic clearance and long-term recovery. EUS-guided gallbladder drainage may allow treatment also of gangrenous cholecystitis including subsequent necrosectomy. To avoid the need for re-intervention, the use of larger-caliber stents or coaxial placement of a double-pigtail plastic stent within the metal stent may be considered in these patients [3]. Article published online: 28 February 2023 © 2023. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using a lumen-apposing metal stent (LAMS) is a novel endoscopic technique for treating gastric outlet obstruction and represents an alternative to stenting or surgery [1] [2]. EUS-GE is minimally invasive and compares favorably with long-term surgical outcomes [1] [2]. Several studies report a high degree of technical and clinical success, despite a considerable rate of complications [1] [3]. A 65-year-old woman with generalized breast cancer presented with signs of gastric outlet obstruction, with a tight duodenal stenosis caused by malignant abdominal lymphadenopathy. EUS-GE was performed using LAMS (20 mm Hot Axios Stent; Boston Scientific, Marlborough, Massachusetts, USA), resulting in immediate resumption of oral intake ([Fig. 1], [Video 1]). Correct positioning of the stent in the small intestine was documented endoscopically and radiologically. Video 1 Gastrojejunocolic fistula as an unusual late complication of endoscopic ultrasound-guided gastroenterostomy. However, 4 months later, the patient complained of dyspeptic symptoms. Gastroscopy was performed, revealing a normal anastomosis with two jejunal loops ([Fig. 2], [Video 1]). Then, 2 months later, gradual development of anorexia, diarrhea, and fecal vomiting was observed. A computed tomography scan indicated possible communication of the stent with the colon ([Fig. 3], [Video 1]). Gastroscopy showed a patent anastomosis between the stomach and jejunum as well as the large intestine. We extracted the LAMS and closed the gastric orifice of the anastomosis with an over-the-scope clip (OTSC; Ovesco Endoscopy GmbH, Tübingen, Germany), through-the-scope clips, and endoloop ([Video 1]), leading to immediate remission of vomiting and significant improvement in diarrhea. Due to ongoing oncological treatment and regression of abdominal lymphadenopathy, restoration of gastrointestinal tract continuity was not necessary. Although an improvement in condition enabled chemotherapy for an additional 3 months, the patient eventually died of disease progression. Endoscopic closure of a gastrocolic fistula following EUS-GE has been successfully performed using a suturing device [4]. Another report described gastrojejunocolic fistula as a rare complication of surgical gastroenterostomy [5]. However, our report is the first to document gastrojejunocolic fistula following EUS-GE, which we successfully resolved with endoscopic treatment. Endoscopy_UCTN_Code_CPL_1AH_2AD Article published online: 28 October 2022 © 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Background Peroral endoscopic myotomy (POEM) is nowadays a standard method for treatment of achalasia; nevertheless, it remains an invasive intervention with corresponding risk of adverse events (AEs). The classification and grading of AEs are still a matter of discussion. The aim of our retrospective study was to assess the occurrence of all “undesirable” events and “true” adverse events in patients undergoing POEM and to compare the outcomes when either Clavien–Dindo classification (CDC) or American Society of Gastrointestinal Endoscopy (ASGE) lexicon classification applied. Methods This was a retrospective analysis of prospectively managed database of all patients who had undergone POEM between December 2012 and August 2018. We assessed the pre-, peri-, and early-postoperative (up to patient’s discharge) undesirable events (including those not fulfilling criteria for AEs) and “true” AEs according the definition in either of the classifications. Results A total of 231 patients have successfully undergone 244 POEM procedures (13 × re-POEM). Twenty-nine procedures (11.9%) passed uneventfully, while in 215 procedures (88.1%), a total of 440 undesirable events occurred. The CDC identified 27 AEs (17 minor, 10 major) occurring in 23/244 (9.4%) procedures. The ASGE lexicon identified identical 27 AEs (21 mild or moderate, 6 severe or fatal) resulting in the severity distribution of AEs being the only difference between the two classifications. Only the absence of previous treatment was found to be a risk factor [p = 0.047, OR with 95% CI: 4.55 (1.02; 20.25)] in the combined logistic regression model. Conclusion Undesirable events are common in patients undergoing POEM but the incidence of true AEs is low according to both classifications. Severe adverse events are infrequent irrespective of the classification applied. CDC may be more appropriate than ASGE lexicon for classifying POEM-related AEs given a surgical nature of this procedure. Graphical abstract