Einas Abou Ali

INTRODUCTION: When initial resection of rectal neuroendocrine tumors (r-NETs) is not R0, persistence of local residue could lead to disease recurrence. This study aimed to evaluate the interest of systematic resection of non-R0 r-NET scars. METHODS: Retrospective analysis of all the consecutive endoscopic revisions and resections of the scar after non-R0 resections of r-NETs. RESULTS: A total of 100 patients were included. Salvage endoscopic procedure using endoscopic submucosal dissection or endoscopic full-thickness resection showed an R0 rate of near 100%. Residual r-NET was found in 43% of cases. DISCUSSION: In case of non-R0 resected r-NET, systematic scar resection by endoscopic full-thickness resection or endoscopic submucosal dissection seems necessary.

Patients and methods: we performed a retrospective case-control study, including cases with repeat EUS FNB for a solid pancreatic lesion, matched on a 1:2 ratio on age, sex, tumor location and presence of chronic pancreatitis with cases diagnosed on the first EUS FNB. Results: thirty-four cases and 68 controls were included in the analysis. Diagnostic accuracies were 80% and 88% in the repeat and single EUS FNB groups, respectively (p = 0.824). The second EUS FNB had a sensitivity of 80%, a specificity of 75%, a positive predictive value of 96%, and a negative predictive value of 33%. Of the 34 patients in the repeat EUS FNB group, 25 (74%) had a positive diagnosis with the second EUS FNB, 4 (12%) after surgery due to a second negative EUS FNB, 4 (12%) during clinical follow-up, and 1 (3%) after a third EUS FNB. Of the 25 patients diagnosed on the repeat EUS FNB, 17 (68%) had pancreatic adenocarcinomas, 2 (8%) neuroendocrine tumors, 2 (8%) other autoimmune pancreatitis, 2 (8%) chronic pancreatitis nodules, 1 (4%) renal cancer metastasis, and 1 (4%) other malignant diagnostic. There were no complications reported after the second EUS FNB in this study. Conclusion: repeat EUS FNB made a diagnosis in three fourths of patients with solid pancreatic lesions and a first negative EUS FNB, with 26% of benign lesions. This supports the repetition of EUS FNB sampling in this clinical situation.

Aims To define a new technique of closure of mucosal defects post endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), using an endoloop system, to assess its rate of technical success and of post resection delayed haemorrhage. Methods After endoscopic resection by EMR or ESD of large colorectal or duodenal lesions (diameter ≥25 mm), two similar techniques of closure of mucosal defects were implemented, using a single-channel colonoscope, with a standard channel diameter (>3.2mm). An endoloop was dropped directly through the working channel or towed parallel to the endoscope, then fixed to the margin of the resection with several clips (at 0, 2, 4, 6, 8, 10 o’clock). The loop is closed either directly or by being reattached to the mobile hook, followed by closure like a purse-string suture. The endoloop is then definitively released. Results 23 patients (52% women, median age 67 years) were included in this analysis, 3 under anticoagulant treatment and 4 with antiplatelet therapy. 22 colorectal and 1 duodenal polyp resections were performed (median size of 40 mm). 10 patients had high risk of post-polypectomy hemorrhage for colonic lesions according to the clinically significant bleeding (CPSEB) score. A technical success was obtained in 100% of cases, 4 patients (17%) necessitating one supplementary endoclip. The rate of clinically significant delayed bleeding, delayed perforation or post-polypectomy syndrome was 0%. Conclusions The presented original methods for closing the mucosal defect, using clips and endoloop, are safe and easy for implementation, allowing an excellent technical success rate and 0% of complications. 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 To define a new technique of endoscopic closure of an iatrogenic perforation, using an endoloop system, to assess its rate of technical success and of post resection complications. Methods After a large iatrogenic perforation (diameter ≥10 mm), during an endoscopic submucosal dissection or transparietal resection of colorectal or gastric lesions, two similar techniques of closure of wall defects were implemented, using a single-channel colonoscope with a standard channel diameter or a gastroscope with a large operating channel (>3.2mm). An endoloop was dropped directly through the operating channel or towed parallel to the endoscope, then fixed with several clips on the margins of the defect, directly to the muscular layer (at 0, 2, 4, 6, 8 and 10 o’clock). The loop was reattached to the mobile hook and closed with an edge-to-edge suture of the muscular layers. Results 8 patients (6 women, median age 67 years) were included in this analysis. 6 colorectal polyps and 2 gastric stromal tumors were resected (median size – 20 mm), with a 17.5 mm median perforation size. Technical success was obtained in 100% of cases, with a median 6 clips used. The median duration of hospitalization was 4 days. Prophylactic antibiotics were prescribed for all the patients (median duration of 7.5 days). 3 pneumoperitoneum evacuations, 1 febrile episode and 1 small non drainable collection were observed, but 0 post-resection bleeding. Conclusions Safe and easy original methods for closing wall defects with a single channel endoscope, using clips and endoloop for an edge-to-edge muscular layer suture, were presented, with excellent technical success rate and minimal complications. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Background. In case of high risk of lymph node invasion after endoscopic resection (ER) of superficial esophageal squamous cell carcinoma (SCC), adjuvant chemoradiotherapy (CRT) can be an alternative to surgery. We assessed long-term clinical outcomes of adjuvant therapy by CRT after non-curative ER for superficial SCC. Methods. We performed a retrospective multicenter study. From April 1999 to April 2018, all consecutive patients who underwent ER for SCC with tumor infiltration beyond the muscularis mucosae were included. Results. A total of 137 ER were analyzed. The overall nodal or metastatic recurrence-free survival rate at 5 years was 88% and specific recurrence-free survival rates at 5 years with and without adjuvant therapy were, respectively, 97.9% and 79.1% (p = 0.011). Independent factors for nodal and/or distal metastatic recurrence were age (HR = 1.075, p = 0.031), Sm infiltration depth > 200 µm (HR = 4.129, p = 0.040), and the absence of adjuvant CRT or surgery (HR = 11.322, p = 0.029). Conclusion. In this study, adjuvant therapy is associated with a higher recurrence-free survival rate at 5 years after non-curative ER. This result suggests this approach may be considered as an alternative to surgery in selected patients.

Aims Zenker's diverticulum usually presents in the elderly population with symptoms of dysphagia. The endoscopic diverticulotomy can be performed using either cap or diverticuloscope assistance. The abandonment of the diverticuloscope for the treatment of diverticula allows to perform a complete septotomy of the diverticular wall in particular in the case of large diverticula (greater than 5 cm). The aim of this study was to evaluate the safety and feasibility of complete septotomy in the setting of large Zenker's diverticula. Methods We conducted a retrospective analysis that included all patients who had endoscopic septotomy for large Zenker diverticulum (greater than 5 cm) between January 2014 and November 2020. The procedure was performed under general anesthesia using a gastroscope with a cap assistance. The complete incision of the diverticulum septum was achieved using a Dual or TT knife, until complete effacement of the diverticulum. The short and medium term clinical results were collected. The clinical success rate was defined as the absence of regurgitation or dysphagia-like symptoms. Results 105 patients have been treated endoscopically for Zenker's diverticulum. Twelve patients had large diverticula. The mean size of the diverticula was 6+/- 1.15 cm. The clinical success rate was 100% and the complication rate was 8%. After a median follow-up of 12.5 months, the clinical success rate was 92% in ITT and 100% in per protocol. Conclusions Complete endoscopic septotomy seems to be an interesting approach for the treatment of large diverticula with a high clinical success rate and low rate of morbidity. Publication Date: 14 April 2022 (online) © 2022. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Aims Gastric linitis plastica (GLP) is a diffuse infiltrating type of gastric adenocarcinoma. It is associated with a poor prognosis and a five-year survival of 3-10%. The infiltrating profile of this tumor explains the low yield of the superficial mucosal biospies. The objective of this study was to investigate the role of endoscopic ultrasound-fine needle biopsy (EUS-FNB) in the diagnosis of GLP. Methods We performed a retrospective analysis including all patients who had a EUS-FNB, for suspected GLP, at a tertiary referral center, over the last 3 years. A GLP was suspected based on the presence of a gastric wall thickening, or perigastric lymph nodes on abdominal CT, or gastric stenosis, enlarged gastric folds, or pangastric infiltration on esophagogastroduodenoscopy. The primary outcome was the sensitivity of EUS-FNB in patients with suspected GLP. Results Between January 2017 and December 2020, 34 patients had a EUS-FNB for suspected GLP. Ten patients had a diagnostic of GLP. This diagnosis was obtained by EUS-FNB in 90% (9/10) of the cases. Eight patients had at least one previous esophagogastroduodenoscopy (EGD) with negative mucosal biopsies. Gastric EUS-FNB helped diagnose other serious conditions in 47% (16/34) of cases with inconclusive mucosal biopsies. Conclusions Gastric EUS-FNB in patients with suspected GLP and normal endoscopic mucosal biopsies may lead to a positive diagnosis of GLP in 90% of cases without notable adverse events. This technique should be considered as a second step in the setting of suspicion of GLP after inconclusive mucosal biopsies. Publication Date: 14 April 2022 (online) © 2022. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Pancreatic neuroendocrine tumors (p-NETs) are rare tumors with a recent growing incidence. In the 2017 WHO classification, p-NETs are classified into well-differentiated (i.e., p-NETs grade 1 to 3) and poorly differentiated neuroendocrine carcinomas (i.e., p-NECs). P-NETs G1 and G2 are often non-functioning tumors, of which the prognosis depends on the metastatic status. In the localized setting, p-NETs should be surgically managed, as no benefit for adjuvant chemotherapy has been demonstrated. Parenchymal sparing resection, including both duodenum and pancreas, are safe procedures in selected patients with reduced endocrine and exocrine long-term dysfunction. When the p-NET is benign or borderline malignant, this surgical option is associated with low rates of severe postoperative morbidity and in-hospital mortality. This narrative review offers comments, tips, and tricks from reviewing the available literature on these different options in order to clarify their indications. We also sum up the overall current data on p-NETs G1 and G2 management.

Parenchymal sparing duodenal and pancreatic resection are safe procedures in selected patients with the aim to reduce endocrine and exocrine long-term dysfunction. When the tumor is benign or borderline malignant, this appears to be a good option for the surgeon, associated with low rates of severe surgery-related early postoperative complications and low in-hospital mortality. This mini review offers comments, tips and tricks, and a review of literature concerning those different options with specific illustrations in order to clarify their indication.