Barbara A. J. Bastiaansen

Background: Screening for colorectal cancer has led to large increases in the detection of large non-pedunculated rectal polyps. Local en bloc removal is increasingly seen as the optimal approach and can be performed by surgical or endoscopic local excision, via transanal minimal invasive surgery (TAMIS) or endoscopic submucosal dissection (ESD) respectively. We hypothesised that ESD would have a non-inferior recurrence rate with less serious adverse events and lower costs than TAMIS. Methods: We performed a multicentre randomised controlled non-inferiority trial in 23 hospitals in the Netherlands. Adult patients with a non-pedunculated rectal polyp larger than two centimetres without features of deep submucosal invasion, were eligible for inclusion. Patients were randomised 1:1 to receive TAMIS or ESD, stratified for the distance from the dentate line and lesion size. The primary outcome was the intention-to-treat recurrence rate at 12 months. The non-inferiority margin was six percent. Netherlands Trial Register, NL7083. Findings: 198 patients were recruited between Jan 1, 2019, and Jan 1, 2023. 98 (57 males) were assigned to TAMIS and 100 (60 males) to ESD. For the primary outcome all randomised patients were analysed. There were six recurrences in the TAMIS arm and none in the ESD arm. The difference in recurrence rate was –6·3% in favour of ESD (95% CI [ –11·2; –1·4]). ESD cost €2,636 (95% CI [2,446; 2,826]) and TAMIS €3,340 (95% CI [3,068; 3611]. There were no treatment related deaths and no significant differences in adverse events. Interpretation: ESD should be the treatment of choice for large non-pedunculated rectal polyps.

INTRODUCTION: Nonexposed endoscopic full-thickness resection (EFTR) using a dedicated full-thickness resection device can be used to perform en bloc resection of subepithelial lesions throughout the gastrointestinal tract. In this article, we aim to evaluate the safety and efficacy of EFTR for the management of duodenal neuroendocrine tumors (dNETs). METHODS: This was an international multicenter retrospective study of device-assisted EFTR for dNET. Study outcomes included rates of technical success, R0 resection, and adverse events (AEs). RESULTS: A total of 171 patients were included across 35 centers. Lesions had a median size of 10 mm and were in the duodenal bulb in 143 cases (83.6%). Technical success was achieved in 164 (95.9%) and R0 resection in 123 cases (71.9%). The R0 resection rate for lesions located in the proximal third of the bulb was 62.0% compared with 83.9% for more distal locations ( P = 0.002). The R0 resection rate was not affected by lesion size or depth of invasion. On multivariable analysis, date of resection (2021 onward) and location distal to the proximal third of the duodenal bulb were independent predictors of R0 resection, but not case volume per participating center. Follow-up information was available for 114 patients (66.7%) and demonstrated 2 recurrences over a median follow-up of 10 months. Severe AEs occurred in 3 patients (1.8%). DISCUSSION: EFTR of dNET showed high technical success and R0 resection rates and very low rate of severe AEs. It could become endoscopic treatment of choice for dNET, at least for lesions not within proximity of the pylorus.

INTRODUCTION: To prevent colorectal cancer, most patients with familial adenomatous polyposis (FAP) undergo (procto)colectomy with ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA). After surgery, these patients remain at risk of developing cancer in the remnant rectum or rectal cuff/pouch. We aimed to compare the long-term risk of cancer after IRA or IPAA in FAP. METHODS: We performed an international multicenter historical cohort study of FAP patients undergoing IRA or IPAA from 1990 to 2023. The proportion of patients developing cancer after surgery was estimated using the Kaplan-Meier method. RESULTS: (Procto)colectomy was performed in 685 patients (53.6% female); 366 (53.4%) had IRA, and 319 (46.6%) had IPAA. Median age at IRA and IPAA was 23 and 27 years, and the median follow-up was 12 and 15 years, respectively. Overall, 8 patients (2.2%) developed rectal and/or rectal cuff/pouch cancer after IRA and 0.9% after IPAA. The estimated 10- and 20-year cancer incidence after IRA vs IPAA was 1.6% vs 0.4% and 2.5% vs 0.9%, respectively (log-rank P = 0.15). Reoperations, mainly for extensive polyposis, were performed in 39 (10.7%) patients with an IRA and 24 (7.5%) patients after IPAA. The number of postoperative endoscopic surveillance endoscopies was higher in patients with an IRA compared with those with an IPAA (P < 0.001). DISCUSSION: Over the past 3 decades, few patients were diagnosed with cancer in the rectum or rectal cuff/pouch after (procto)colectomy in FAP. This might be due to an improved selection of the type of (procto)colectomy and close endoscopic surveillance including prophylactic polypectomies.

INTRODUCTION: Peroral endoscopic myotomy (POEM) may result in a distended distal esophagus, referred to as a blown-out myotomy (BOM), the relevance of which is uncertain. The aim of this study was to investigate the prevalence, risk factors, and associated symptoms of BOM after achalasia treatment. METHODS: A data set of the locally treated patients in a randomized controlled trial comparing POEM with pneumatic dilation (PD) was analyzed. A BOM is defined as a >50% increase in esophageal diameter at its widest point in the distal esophagus between the lower esophageal sphincter and 5 cm above. RESULTS: Seventy-four patients were treated in our center, and 5-year follow-up data were available in 55 patients (32 patients [58%] randomized to POEM, 23 [42%] PD). In the group initially treated with POEM, the incidence of BOM increased from 11.5% (4/38) at 3 months, to 21.1% (8/38) at 1 year, 27.8% (10/36) at 2 years, and 31.3% (10/32) at 5 years. None of the patients treated with PD alone developed a BOM. Patients who developed a BOM had a higher total Eckardt score and Eckardt regurgitation component compared with patients who underwent POEM without BOM development (3 [2.75–3.25] vs 2 [1.75–3], P = 0.032, and 1 [0.75–1] vs 0 [0–1], P = 0.041). POEM patients with a BOM more often report reflux symptoms (85% [11/13] vs 46% [2/16], P = 0.023) and had a higher acid exposure time (24.5% [8–47] vs 6% [1.2–18.7], P = 0.027). DISCUSSION: Thirty percent of the patients treated with POEM develop a BOM, which is associated with a higher acid exposure, more reflux symptoms, and symptoms of regurgitation.

Background and study aims Some patients with familial adenomatous polyposis (FAP) and extensive duodenal polyposis or cancer require total duodenectomy. Regular postoperative endoscopic surveillance of the remaining jejunum and stomach is recommended, but little is known about the outcomes after this surgery. Patients and methods Patients with FAP who underwent either pancreatoduodenectomy (PD) or pancreas-preserving total duodenectomy (PPTD) were identified at two expert centers. Data about postoperative endoscopic surveillance outcomes were collected, as well as survival outcomes. Results Overall, 119 patients (50% female) underwent duodenectomy (86 PD and 33 PPTD); 100 for benign duodenal polyposis and 19 for duodenal or ampullary cancer. Details of postoperative endoscopic surveillance were available for 88 patients (74%). During a median follow-up of 106 months, 36 patients (41%) were diagnosed with jejunal adenomas after duodenectomy, with a significantly higher proportion in patients who underwent PPTD compared with patients who underwent PD (log-rank, P < 0.01). Two patients developed jejunal cancer (2%). Twenty-six patients (30%) were diagnosed with a total of 66 gastric adenomas, of which 61% were located in the fundus/body and 39% in the antrum. Five patients (6%) developed gastric cancer after a median of 15 years (range 6–23 years), all but one within carpeting fundic gland polyposis. Patients who underwent surgery for cancer had worse survival than patients with benign disease and all but one patient with postoperative gastric/jejunal cancer died. Conclusions After duodenectomy in FAP, a considerable risk of developing adenomas and cancer in the stomach and jejunum exists with poor cancer prognosis, highlighting the need for close postoperative endoscopic surveillance.

Aims Most patients with familial adenomatous polyposis (FAP) develop duodenal adenomas, but only 4-10% duodenal cancer. In an attempt to prevent cancer or prevent/delay duodenal surgery, endoscopic polypectomy is recommended. Adverse events (AEs) after duodenal polypectomy in the duodenum polypectomy include 2-3% perforation and 13-20% delayed bleeding, but these data are largely from hot snare polypectomy. We hypothesized that cold snare polypectomy (CSP) is a safe technique for superficial non-ampullary duodenal adenomas in FAP and reviewed our outcomes from CSP. Methods We performed a prospective international cohort study including patients with FAP who underwent CSP for one or more superficial non-ampullary duodenal adenomas between 2020 and 2022. The primary outcome was incidence of intra- and post-procedural AEs. Results In 40 patients with FAP, 136 CSPs were performed (ranging 1-18 CSPs per session). Median polyp a size was 10mm (IQR 8-15mm) and range 5-40mm. Twenty-seven adenomas were ≥20mm. 109/136 (80%) polyps (80%), were lifted by submucosal injection before CSP. Sixty-five polyps (48%) were resected en bloc and 71 polyps (52%) piecemeal. Macroscopic radical resection was achieved in 132 lesions (97%). In 8.1% of cases, the defect was prophylactically clipped to prevent bleeding. One intraprocedural bleeding occurred which was managed by hemoclips, no perforation and no other intra- or post-procedural complications. Histopathology showed low-grade dysplasia only. Conclusions Cold snare polypectomy is feasible and safe for superficial non-ampullary duodenal adenomas any size in FAP when performed by experienced endoscopists. 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 this study was to compare the long-term risk of cancer following colectomy with ileorectal/ileosigmoidal anastomosis (IRA/ISA) and proctocolectomy with ileal pouch-anal anastomosis (IPAA) in patients with familial adenomatous polyposis (FAP). Methods We performed an international multicenter retrospective cohort study of FAP patients undergoing colectomy with IRA/ISA or proctocolectomy with IPAA between 1990 till 2022. The proportion of patients developing cancer following surgery was estimated using the Kaplan Meier method. Results In total, (procto)colectomy was performed in 588 patients (53.9% female); 309 (52.6%) had IRA/ISA and 279 (47.4%) IPAA. Median age at IRA/ISA and IPAA was 21 and 27 years, and median follow-up 12 and 15 years, respectively. The incidence of cancer following IRA/ISA was 1.9% and 1.1% following IPAA. The cumulative 10- and 20-year cancer free survival rates (IRA/ISA vs IPAA) were 99.0% vs 99.6% and 97.9% vs 99.0%, respectively (log-rank p = 0.32). All patients who developed cancer survived. Endoscopic follow-up data was available in 514 patients (87.4%). The median number of surveillance endoscopies was 11 versus 8 in the IRA/ISA and IPAA group, respectively (p < 0.001). In the IRA/ISA group, the median number of polypectomies was 32 and in the IPAA group 2 (p < 0.001). Conclusions During the last three decades, the risk of distal cancer after (procto)colectomy in FAP was low. This seems to be the result of appropriate selection of the type and timing of colectomy and frequent endoscopic surveillance including polypectomy. 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 Endoscopic intermuscular dissection(EID) was recently introduced for rectal deep submucosal invasive cancer(D-SMIC). EID has shown high radical resection rates for D-SMIC(93%), but little is known about post-procedural recovery and functional outcomes. Methods A prospective registry of EID procedures for suspected rectal D-SMIC between '18-'22 was used. Details on post-procedural recovery, pain and functional outcome using a validated low anterior resection syndrome (LARS) questionnaire were collected by telephone surveys. Results 140 patients underwent EID (median age 65yrs, 70% male, mean tumor size 29mm) of whom 96(68.6%) had rectal preservation, including 12(8.6%) with adjuvant chemoradiotherapy(CRT). Intentional or accidental transmural defects >1cm occurred in 19(13.6%), for which closure in 15/19. After EID, 135(96.5%) patients were discharged <24 hours and 4(2.9%) patients were readmitted due to pain[1], fever[1] or delayed bleeding[2], without transfusion/intervention. Two(1.4%) needed dilation for stenosis. Survey response rate was 83.6%. Of responders, 70.9% resumed daily routine 4cm, but not to transmural defects. Major/minor LARS after EID alone was 5.9%/7.4%, after adjuvant CRT 0%/27.3%, and after completion TME 25%/20% respectively, at a median FU of 20 months. Conclusions EID is a safe procedure with rapid recovery and a low risk of serious adverse events or long-term bowel dysfunction. Post-procedural pain should be anticipated for lower rectum lesions. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany