ISSN / EISSN : 0935-8943 / 1438-8685
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Background and study aims Several techniques exist for the eradication of Barrett’s esophagus (BE); however, all have limitations regarding successful conversion to squamous epithelium and a complication profile. We aimed to assess the feasibility and safety of a new non-thermal device, the EndoRotor, for the eradication of BE as a first-line ablation technique. Patients and methods Patients with BE were prospectively included in 2 tertiary referral centers in The Netherlands. Inclusion criteria: BE-length 2-5cm, with low-grade dysplasia, high-grade dysplasia or residual BE after endoscopic resection (ER) of a lesion containing early neoplasia. Exclusion criteria: previous ER >50% circumference, or previous ablation therapy. Follow-up endoscopy was performed after 3 months. Outcomes were the percentage of endoscopically visible BE surface regression and complications. Results Thirty patients (25 male, age 66 years [IQR: 59–73], median BE C0M3) were included. Eighteen patients underwent ER prior to ablation. Median percentage BE ablated was 100% (IQR: 94-100). Median visual BE surface regression at three-months follow-up was 80% (IQR: 68–95). Multiple residual Barrett’s islands were commonly seen. Six patients(20%) had a treatment-related complication requiring intervention, including one perforation(3%), one postprocedural hemorrhage(3%), and four strictures(13%). Post-procedural pain was reported in 18 patients(60%). Conclusions For the endoscopic ablation of BE, the EndoRotor procedure was found to be technically demanding with a longer procedure time compared to established ablation techniques and a high complication rate. Based on these results, we do not recommend the EndoRotor as a first-line ablation technique for the eradication of BE.
Since its first description in 2004 by Ganz et al. , radiofrequency ablation (RFA) has become the standard treatment of flat dysplastic Barrett’s esophagus (BE) after endoscopic resection of all visible lesions. Compared with alternative eradication methods, such as stepwise endoscopic resection, (hybrid) argon plasma coagulation, and cryoablation, RFA is the best validated and most used ablation method that is both effective and relatively safe, and is unanimously recommended by various guidelines. “Moving forward, the optimal management strategy for patients without, after successful or after failed RFA will require individual clinical risk-stratification tools that balance the risks of the procedure, progression, and death related to esophageal cancer against the patient’s age and life expectancy, comorbidities, and the risk of death from other diseases.” RFA achieved complete esophageal resurfacing to normal squamous epithelium after a median of three sessions in 94 % of patients in the Dutch Barrett’s registry . In the Netherlands, the management of patients with early neoplastic BE is uniquely organized, with care centralized in high-volume Barrett’s Expert Centers that follow an agreed treatment protocol, and a data registry maintained since 2008. Studies from other groups have reported lower complete remission rates of BE after RFA. Hence, consensus on a suggested minimum complete ablation rate of BE as a quality parameter remains difficult. The UK registry demonstrated an improvement in the RFA results over time as experience in the method increases . Following their previous RFA outcome study, van Munster et al.  present results of an observational study, again based on data from the Dutch Barrett’s Expert Center registry, in this issue of Endoscopy. The study provides a detailed analysis of the characteristics and outcomes of patients with neoplastic BE who had a poor response to RFA therapy. From this registry, 1386 patients who underwent at least one RFA session for treatment of Barrett’s neoplasia were included (73 % with high grade dysplasia or early cancer). A total of 134 patients (10 %) were poor healers but all achieved complete esophageal healing after additional time and intensified reflux therapy with increased doses of proton pump inhibitors. Among the poor healers, 66 % finally achieved complete eradication of BE (CE-BE); however, stricture development was significantly higher compared with patients with normal healing (34 % vs 14 %; P < 0.01). After complete mucosal healing, half of the initially poor healers had achieved more than 50 % squamous regeneration after the first RFA, and all but two of these patients eventually achieved excellent RFA results (97 % CE-BE). Conversely, 74 of the 1386 patients (5 %) had poor squamous regeneration after the first RFA session and 47 of these patients (64 %) did not achieve CE-BE. The residual Barrett’s burden probably explains the observed higher rate of progression to advanced disease in this group of patients with poor squamous regeneration after RFA. The endoscopic definitions of poor healing (active inflammatory changes with mucosal swelling and exudates and/or presence of ulcerations ≥ 3 months after RFA) and poor squamous regeneration (< 50 % BE regression) present challenges in clinical practice as these features are difficult to estimate when unusually shaped Barrett’s areas and large islands remain after RFA. Regenerative and inflammatory alterations after RFA are often hard to distinguish from neoplastic changes. The endoscopic assessment of inflammation and the quantification of squamous regeneration is very operator dependent and subject to bias. The Prague classification that reports the extent of BE by estimating the circumferential and maximal length is often not helpful or not applicable after RFA. Artificial intelligence-based methods promise to reliably quantify the residual area of BE after RFA in three-dimensional reconstruction of the esophageal mucosa . Smart algorithms that support the endoscopist in recognition of inflammation and neoplasia based on the endoscopic appearance and morphology are under clinical evaluation . Current guidelines remain silent on how to manage patients with residual BE despite several RFA attempts. Patients with poor squamous regeneration are mainly also those with poor mucosal healing (91 % in the van Munster study). A pragmatic approach to a poor healing response would be to postpone RFA for at least 6 weeks in order to check the patient’s compliance and maximize the antireflux medication including proton pump inhibitors and additional H2 antagonists. To avoid poor healing, it seems mandatory to control the reflux before embarking on endoscopic treatment. Fortunately, time is on our side in cases of poor response without dysplasia and without worrying endoscopic features. Visible lesions that emerge/resurface after RFA can be treated by endoscopic resection and should not be ablated. Endoscopic surveillance with the option of endoscopic resection seems a reasonable option, at least in frail patients or in those with significant comorbidities and limited life expectancy. In this and other studies, certain risk factors have been identified to predict poor response to RFA: higher body mass index, longer BE length, reflux esophagitis, genetic biomarkers, and poor squamous regeneration after first endoscopic treatment. Most recently, the thickness of the Barrett’s epithelium measured by volumetric laser endomicroscopy has also emerged as a predictor of RFA response. An increase in the mean Barrett’s epithelium thickness of 100 μm resulted in a 12 % lower response to RFA when this was assessed as percentage reduction in Prague score . Whether adaptation of the ablation energy to the thickness of the Barrett’s mucosa would result in higher rates of complete...
Background Suboptimal lifting increases complexity of endoscopic mucosal resection (EMR) for benign colorectal polyps. Cap-assisted EMR (EMR-C) may allow fibrotic polyp tissue to be captured in the snare. This study evaluated the efficacy and safety of EMR-C for benign nonlifting colorectal polyps. Methods This was a multicenter study, which prospectively registered all EMR-C procedures (2016–2018) for presumed benign nonlifting colorectal polyps. Results 70 nonlifting polyps with a median size of 25 mm (interquartile range [IQR] 15–40) were treated with EMR-C. Complete polyp removal was achieved in 68 (97.1 %), including 47 (67.1 %) with EMR-C alone. Overall, 66 polyps showed benign histology, and endoscopic follow-up after a median of 6 months (IQR 6–10) showed recurrence in 19.7 %. First (n = 10) and second (n = 2) benign recurrences were all treated endoscopically. Deep mural injury type III–V occurred in 7.4 % and was treated successfully with clips. Conclusion EMR-C may be an alternative therapeutic option for removal of benign nonlifting polyp tissue. Although recurrence still occurs, repeat endoscopic therapy usually leads to complete polyp clearance.
Positionspapier: Hinweise zur Patienteninformation und -aufklärung vor Anwendung von Biologika bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) – Teil 2: Omalizumab – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)
Zusammenfassung Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung, oftmals auf der Grundlage einer Typ-2-Inflammation. Für die Behandlung von Patienten mit einer schweren Ausprägung ohne ausreichendes Ansprechen auf die Standardtherapie mit topischen nasalen Steroiden und/oder Zustand nach endonasaler Operation sind als Biologika aktuell Dupilumab und Omalizumab für die Therapie zugelassen. Nachdem wir in einer früheren Publikation für Dupilumab bereits entsprechende Hinweise gegeben haben, ist das Ziel der vorliegenden Arbeit die Standardisierung von Patienteninformation und -aufklärung vor einer Therapie mit Omalizumab. Methoden Auf Grundlage des aktuellen Wissensstandes zur Immunologie der CRSwNP und zu den erwünschten und möglichen unerwünschten Wirkungen von Omalizumab werden Empfehlungen für die Patienteninformation entwickelt. Ergebnisse Basierend auf der internationalen Literatur, der aktuellen Fachinformation und Erfahrungen aus der praktischen Anwendung und den derzeitigen Pharmakovigilanz-Daten hat ein Expertengremium Empfehlungen für die Patienteninformation und -aufklärung zur Anwendung von Omalizumab bei CRSwNP entwickelt und auf dieser Grundlage einen Patienteninformations- und Aufklärungsbogen erstellt. Schlussfolgerung Die Information und Einwilligung des Patienten wird vor der Verordnung bzw. Verabreichung von allen Biologika, damit auch Omalizumab, empfohlen. Das vorliegende Positionspapier enthält wichtige Informationen zur praktischen Umsetzung und einen Vorschlag für eine Patienteninformation.
Tattoos are all the rage. Once the exclusive territory of sailors, there are now nearly twenty television programs devoted to tattoos and it almost seems as if no self-respecting professional sportsman would be seen without one. The placement of tattoos endoscopically in the colon has been described for over 50 years. With the rise of laparoscopic resection for colorectal cancer, surgeons have increasingly recommended the preoperative placement of a tattoo to enable them to swiftly and accurately locate colorectal tumors and prevent the inadvertent resection of the wrong segment or inadequate resection margins. In a meta-analysis, tattoo placement lowered the risk of location errors from 16% to 10% . “Before a decision can be taken to recommend not placing tattoos to mark polypectomy sites, it would be wise to perform additional research.” Several gastroenterological societies have published guidelines on tattoo placement. European Society for Gastrointestinal Endoscopy (ESGE) guidelines recommend that lesions which may need to be located again during future endoscopic or surgical procedures should be tattooed during colonoscopy using highly purified carbon particles (Spot; GI Supply, Camp Hill, Pennsylvania, USA) . Two or three separate injections should be performed into the submucosa ≥3 cm from the lesion on the anal side, with initial creation of a saline bleb to prevent inadvertent injection into the peritoneum. While this is a good thing for lesions that proceed to surgical resection, little attention has been paid to the potential disadvantages of tattoo placement or its necessity in lesions that are suitable for endoscopic resection. With screening programs leading to a shift toward the detection of colorectal neoplasia at earlier stages, the relative proportions of lesions proceeding to surgery or endoscopic therapy have also changed, with a far larger proportion now treated exclusively endoscopically. Tattoo placement is not usually necessary to help find lesions during subsequent endoscopic resections. Not only does it not help, it frequently complicates endoscopic resection when tattoo ink has spread under the polyp. The diffusion of tattoo ink is variable but can extend over several centimeters and leads to submucosal fibrosis, making the formation of the submucosal fluid cushion necessary for safe endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) impossible . There have been reports of perforations at polypectomy as a result . Nevertheless, large numbers of benign colorectal lesions are marked endoscopically with tattoos at the initial colonoscopy. This occurs for several reasons. First, despite improvements in training in optical diagnosis and increasing recognition of the limitations of endoscopic biopsies, many colonoscopists still rely on biopsies to differentiate between benign and malignant lesions. If all surgical referrals must be tattooed, relying on histopathology will mean that all large lesions will require tattooing. Second, as already mentioned, rigid quality indicators in endoscopy, where the disadvantages of tattoo placement are insufficiently recognized, push endoscopists toward placing tattoos . Lastly, and most relevant here, tattoos are felt to be necessary to help detect the polypectomy scar at endoscopic surveillance to check for residual or recurrent polyp tissue in or around the scar. In this edition of Endoscopy, Michael Bourke and his prolific research group from Westmead Hospital, Australia try to bring some evidence to the discussion regarding the necessity of tattoo placement to aid in the subsequent detection of the polypectomy site . Their results showed that there was no difference in the detection rate of the polypectomy scar between lesions that were marked with a tattoo and the majority in which no tattoo was placed. While this is welcome evidence, it should be noted that there are some limitations. In this series, whether to place a tattoo or not was left to the discretion of the endoscopist, raising the possibility that polyps in positions that would be difficult to relocate may have been more likely to receive a tattoo. Second, while polypectomy scars can be reliably found without a tattoo, perhaps it is quicker to find them if a tattoo has been placed. This could not be ascertained from their study. Third, the detection of the polypectomy scars described here was predominantly at the first post-polypectomy surveillance colonoscopy 6 months after polypectomy. While a smaller number of scars were also reliably detected after a year, it is conceivable that, without a tattoo, scars will become more difficult to detect over time. Before a decision can be taken to recommend not placing tattoos to mark polypectomy sites, it would be wise to perform additional research into these issues. At the same time colonoscopists who choose not to place a tattoo should make sure that they document the polyp position as accurately as possible, based on reliable landmarks and the position of the patient required for optimal visualization, and preferably not only the, frequently unreliable, insertion distance of the colonoscope beyond the anus. Good photographic documentation of the polyp site and a photograph of the magnetic colonoscope imaging picture should also facilitate the subsequent detection of the polypectomy site. Publication Date:13 September 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KGRüdigerstraße 14, 70469 Stuttgart, Germany
Zusammenfassung Hintergrund Im Dezember 2019 begann sich die COVID-19-Pandemie weltweit auszubreiten und sorgte für massive Einschränkungen im täglichen Leben. Viele Bildungseinrichtungen und logopädische Praxen wurden vorübergehend geschlossen (sog. Lockdown). Kinder mit einer Sprachentwicklungsstörung waren gezwungen, ihre Therapie zu pausieren. Ziel dieser Studie war es zu beschreiben, ob und wie die logopädische Therapie während des Lockdowns durchgeführt wurde und welche psychische Belastung für die betroffenen Eltern damit verbunden war. Material und Methoden Eltern von Kindern mit einer Sprachentwicklungsstörung wurden über die Therapie ihres Kindes während des Lockdowns und über ihre damit verbundenen Ängste und Sorgen befragt. Ergebnisse Bei 17 Patienten wurde die Sprachtherapie während des Lockdowns pausiert, während 20 Patienten ihre Therapie fortsetzen konnten. Kinder, die eine andere Sprache als Deutsch sprachen, hatten ein höheres Risiko, dass ihre Therapie pausiert wurde (Odds Ratio (OR) 5,11; 95 %-Konfidenzintervall (KI) 1,09–32,54). Eltern, deren Kinder während des Lockdowns keine Sprachtherapie erhielten, machten sich mehr Sorgen um die Entwicklung ihres Kindes. Schlussfolgerungen Es gibt kein generelles Konzept, wie Logopädie während eines Lockdowns sicher durchgeführt werden kann. Mögliche Barrieren für die Gesundheitsversorgung könnten während der Pandemie stärker ausgeprägt sein. Die betroffenen Eltern erleben eine höhere psychosoziale Belastung.
Objective: Gastrointestinal (GI) fistula, a life-threatening condition, represents a therapeutic challenge. Rescue surgery could be hazardous and/or impact quality of life justifying endoscopic con-servative approach including mucosal abrasion, clip closure or stent diversion with moderate success rates in the long term. We assessed whether Fistulas Endoscopic Submucosal Dissection with clip Closure (FESDC) could lead to complete resolution of fistulas even if previous endoscopic therapy failed. Results: 23 patients with GI fistulas were retrospectively included, 57% of those were defined as refractory fistulas since previous endoscopic treatment failed. Tight immediate sealing was obtained for 19 patients (83% [95% CI: 61%, 95%]) who received FESDC. Long term closure (>3 months) was obtained in 14 cases (61% [95% CI: 39%, 80%]) with a median follow-up of 20 months. Ad-verse events occurred in 9% of cases. Previous local malignancy (p=0.077) or radiation therapy (p=0.047) were associated with a higher risk of failure. Conclusion: The new FESDC strategy is safe and allows permanent endoscopic closure of GI fistulas in 61% of the patients, and 54% of those with previous attempt. Further studies are war-ranted to determine the place of this technic in the management of chronic GI fistula.
Endoscopic submucosal dissection (ESD) is the technique of choice for the resection of large superficial colorectal lesions , but it can be technically challenging in some situations. For this reason, lesions involving the appendiceal orifice have long been removed surgically. However, recent findings have found that ESD is effective and safe in that situation  , even for lesions deeply invading the appendiceal orifice (Toyonaga 3 lesions) with the help of traction device  . Here we report the case of a 70-year-old woman with a history of appendectomy who underwent a colonoscopy that revealed a granular lateral spreading tumor (LST-G) of 3 cm invading the previous site of the appendectomy (Toyonaga 3a) ([Fig. 1]). An ESD using a multi-intertwined loop device was chosen ([Video 1]). After circumferential mucosal incision around the lesion, the first loop of the device was attached to one edge of the lesion with a hemostatic clip. Then a second loop was attached to the opposite edge of the lesion. Then the entire device was attached to the opposite colonic wall. The submucosal space was well exposed at the two edges of the LST-G, allowing a safe dissection during the whole procedure with an en-bloc resection ([Fig. 2], [Fig. 3]). The patient was discharged the day after without experiencing any adverse event. The pathology report showed a high-grade dysplasia with a focus of intramucosal adenocarcinoma that was completely resected by the ESD. Owing to the curative resection, an endoscopic follow-up was decided. Video 1 Endoscopic submucosal dissection of a lateral spreading tumor involving the appendiceal orifice using a multi-traction device. This case highlights that ESD can be safely performed in the appendiceal orifice even with a history of appendectomy. The use of a multi-traction device helped to obtain very satisfying exposure of the submucosal space. A randomized control study evaluating this device would be necessary to confirm this promising result. Endoscopy_UCTN_Code_TTT_1AQ_2AJ Publication Date:08 September 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KGRüdigerstraße 14, 70469 Stuttgart, Germany
Endoscopic submucosal dissection (ESD) is a widely used technique associated with high en bloc resection rates for colorectal lesions , but at the cost of a higher incidence of adverse events, such as delayed bleeding and perforation, compared with endoscopic mucosal resection . To prevent such complications, closure of ESD-induced mucosal defects is pursued, although this task can become challenging owing to their large size . Herein, we report a new closure method for ESD-induced defects using endoclips and an elastic-rubber ring designed for orthodontics, which we have called the closure method with an elastic-rubber ring (CMER). CMER is a modification of the loop–clip closure technique using a rubber band  . A 3-mm elastic-rubber ring (Ormco, Orange, California, USA) ([Fig. 1 a]) is tied with a 3–0 nylon thread onto either “arm” of a semi-open endoclip (HX-610-090; Olympus, Tokyo, Japan) ([Fig. 1 b]), which is then retracted into the sheath. The sheath is introduced through a single-channel endoscope and the clip with the attached elastic-rubber ring is “anchored” at the anal side of the ESD defect. The elastic-rubber ring is then “hooked” with another endoclip and fixed to the oral side of the defect. The tension generated by the elastic-rubber ring pulls the resection margins closer. This process is repeated, subsequently leading to further margin approximation and finally to complete closure with the addition of some further endoclips ([Fig. 2]). In the illustrated case, CMER was performed, as described above, post-ESD for cancer in the upper rectum. At repeat endoscopy on day 4 post-ESD, the defect remained completely closed, and complete healing of the defect was documented after 2 months ([Fig. 3]; [Video 1]). Video 1 Application of closure method with an elastic-rubber ring (CMER) to achieve complete closure of a mucosal defect after endoscopic submucosal dissection in the proximal rectum. CMER uses tension induced by an elastic-rubber ring to reduce the defect size, which thereby facilitates complete clip closure, while at the same time distributing the tension burden across the clips to prevent separation. All of the instruments used can be introduced through the working channel, therefore scope retraction and re-insertion is unnecessary. In conclusion, CMER is a simple, inexpensive, and effective technique for complete durable closure of ESD-induced defects in the colorectum. Endoscopy_UCTN_Code_CCL_1AD_2AB Publication Date:08 September 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KGRüdigerstraße 14, 70469 Stuttgart, Germany
Background and study aim: There is no enough data for endoscopic resection (ER) of superficial duodenal epithelial tumors (SDETs) due to its rarity. There are two main kinds of ER techniques for SDETs: EMR and ESD. In addition, modified EMR techniques, underwater EMR (UEMR) and cold polypectomy (CP), are getting popular. We conducted a large-scale retrospective multicenter study to clarify detailed outcomes of duodenal ER. Patients and methods : Patients with SDETs who underwent ER at 18 institutions from January 2008 to December 2018 were included. The rates of en bloc resection and delayed adverse events (AEs) (defined as delayed bleeding or perforation) were analyzed. Local recurrence was analyzed using Kaplan-Meier method. Results: In total, 3107 patients (including 1017 receiving ESD) were included. En bloc resection rates were 79.1%, 78.6%, 86.8%, and 94.8%, and delayed AE rates were 0.5%, 2.2%, 2.8%, and 7.3% for CP, UEMR, EMR and ESD, respectively. The delayed AE rate was significantly higher for ESD group than non-ESD group among lesions less than 19 mm (7.4% vs 1.9%, p<0.0001), but not among lesions larger than 20 mm (6.1% vs 7.1%, p=0.6432). The local recurrence rate was significantly lower in ESD group than non-ESD group (p<0.001). Furthermore, for lesions larger than 30 mm, the cumulative local recurrence rate at 2 years was 22.6% in non-ESD group compared to only 1.6% in ESD group (p<0.0001). Conclusions: ER outcomes for SDETs were generally acceptable. ESD by highly experienced endoscopists might be an option for very large SDETs.