Background:Advances in colorectal cancer (CRC) screening and endoscopic techniques have led to increased detection of T1 CRC. Patient management relies on histopathological criteria predicting lymph node metastasis (LNM), including submucosal invasion depth (SID) >1000 µm. However, the independent prognostic value of isolated deep invasion remains unclear. Methods:We performed a retrospective multicenter study of patients treated at 18 European centers between 2009 and 2022. Patients with T1 CRC endoscopically resected en bloc and with isolated SID >1000 µm (without other high-risk features) were included. Two groups were analyzed: patients who underwent additional surgery and those who were followed with surveillance. Rates of LNM (surgery group) and recurrence (local and distant; surveillance group) were assessed. Exploratory multivariable analyses were performed to evaluate clinicopathological factors associated with LNM. Results:Among 179 included patients (124 surgery, 55 surveillance), LNM was found in 16/124 surgical specimens (12.9%; 95%CI 7.7-20.4) and recurrence occurred in 2/55 patients undergoing surveillance (3.6%; 95%CI 0.4-12.6). LNM occurred in 1/50 patients (2.0%) with SID <2000 µm and in 15/74 patients (20.3%) with SID ≥2000 µm. Multivariable analysis revealed SID ≥2000 µm (odds ratio [OR] 3.59; 95%CI 1.14-13.71) and colonic (vs. rectal) tumor location (OR 3.63; 95%CI 1.07-16.77) as factors associated with LNM. Conclusion:Isolated deep submucosal invasion in T1 CRC was associated with a non-negligible rate of LNM in this real-world cohort. In exploratory analyses, SID ≥2000 µm was associated with LNM.

INTRODUCTION:Gastroesophageal reflux disease (GERD) can develop following peroral endoscopic myotomy (POEM). Despite reports of high rates of acid exposure time (AET), limited research examined acidification patterns or contributing factors using esophageal impedance-pH monitoring. OBJECTIVE:To assess the incidence and characteristics of reflux after POEM by analysing esophageal acidification patterns on pH-impedance monitoring. METHODS:We prospectively included patients with primary esophageal motility disorders who underwent POEM between June 2018 and October 2022. GERD was assessed at 3 and 12 months using clinical questionnaires, endoscopy, manometry, and pH-impedance testing evaluated by manual analysis. RESULTS:Among 55 patients, GERD-Q score ≥8 was observed in 7% at 3 months and 9% at 12 months. Esophagitis occurred in 28% at 3 months and 24% at 12 months, with severe cases (grade C) in 7% and 5%, respectively. Pathologic AET was noted in 54% at 3 months and 52% at 12 months. After excluding "non-true acid reflux" (acid fermentation and esophageal stasis) by manual pH tracing review, GERD rates decreased to 46.3% and 36.3% at 3 and 12 months, respectively. Prior proton pump inhibitor use and longer esophageal myotomy were associated with clinical reflux (GERD-Q ≥8) at 12 months in exploratory multivariable analysis. CONCLUSIONS:The incidence of post-POEM GERD is considerably lower after a detailed manual analysis of pH tracings; their review allows differentiation of non-true acid reflux in pathological AET. These findings highlight the importance of careful interpretation of pH-impedance monitoring when evaluating reflux after POEM.

AIMS:To determine the efficacy and safety of endoscopic resection of appendiceal orifice (AO) lesions. Primary endpoints were recurrence rate and the need for additional interventions during a clinical follow-up of at least 12 months and/or one surveillance colonoscopy. METHODS:Retrospective analysis of consecutive endoscopic resection of appendiceal lesions performed at eight centers in Spain between January 2016 and July 2023. Endoscopic resection techniques included endoscopic mucosal resection, underwater EMR (UEMR), endoscopic full-thickness resection, or endoscopic submucosal dissection. RESULTS:A total of 97 lesions were treated (median size 18 mm), 32 showing deep intra-appendicular involvement, and 62 having ≥50% circumferential involvement. UEMR was used in 52% of cases. Technical success was 93% (48% en-bloc resection). There were 6 intraprocedural and 1 postprocedural bleeding and 1 intraprocedural perforation managed endoscopically, but no cases of early post-resection appendicitis. During a median endoscopic follow-up of 23 months (n=51), 13 recurrences (25%) were identified (median time 10 months[IQR]=9-20). Piecemeal resection was significantly associated with recurrence (univariate). Deep AO extension, size ≥2cm and previous manipulation were significantly associated with piecemeal resection (multivariate). Surgery was required in 12 cases due to incomplete resection (n=7), malignancy (n=1), residual adenoma (n=2) and delayed post-resection appendicitis (n=2; at 11- and 56-months post-resection). CONCLUSIONS:Endoscopic management of AO lesions is effective and safe. However, recurrence risk emphasizes the need for long-term follow-up. Further research is required to assess delayed appendicitis risk and the optimal management of deep extension AO lesions.

A 66-year-old woman with a history of Sjögren's syndrome without visceral involvement, and low-grade non-Hodgkin lymphoma without mediastinal involvement, treated with rituximab in 2022 and in complete remission, was referred to Gastroenterology for progressive upper dysphagia of 10 years' duration. Dysphagia was initially limited to solids, but progressively worsened to involve both solids and liquids, requiring a soft or puréed diet. She also reported a 10% loss of body weight, with no heartburn, regurgitation, or other associated symptoms (Eckardt score 5).

BACKGROUND AND AIMS:Cholecystectomy is recommended to prevent recurrence of biliary pancreatitis, but supporting evidence is limited for sludge- and microlithiasis-induced acute pancreatitis (AP). This study aimed to compare relapse patterns and risk factors between patients with sludge/microlithiasis-induced AP and gallstone-induced AP. METHODS:This analysis included 789 patients from the international, multicenter Relapstone cohort (Spain: 16 centers; Mexico: 2 centers), hospitalized between January 2018 and April 2020 with first-time biliary AP and no cholecystectomy during admission. Patients with sludge/microlithiasis-induced AP (n = 274) were compared to those with gallstone-induced AP (n = 515) regarding pancreatobiliary complications. Multivariate analysis was used to assess relapse risk factors. RESULTS:Pancreatobiliary complications occurred in 41.7 % of the gallstone cohort versus 32.1 % in the sludge/microlithiasis cohort (p = 0.01). Correspondingly, the gallstone AP cohort showed a significantly lower complication-free survival rate (log-rank p = 0.0022; median follow-up: 6.1 vs. 8.1 months). In multivariate analysis, older age in the gallstone group was significantly associated with lower relapse risk (HR = 0.54, 95 % CI: 0.39-0.74). CONCLUSION:This multicenter study reveals distinct differences in relapse risk between gallstone- and sludge/microlithiasis-induced AP, with gallstone AP showing a higher rate of complications in the absence of cholecystectomy.

Percutaneous endoscopic gastrostomy is performed to gain enteral nutritional access in patients with impaired swallowing. However, gastrocutaneous fistula (GCF) may persist in up to 25% of cases following tube removal [11]. Endoscopic submucosal dissection (ESD) to re-epithelialize the fistulous tract, combined with closure using an over-the-scope (OTS) clip, has been reported as a safe and effective approach for managing persistent GCF [22] [33] [44]. A twin grasper is commonly used to pull the GCF into the OTS clip before the clip is deployed. A recently introduced, mantis-like claw clip – Mantis clip (Boston Scientific, Marlborough, Massachusetts, USA) – has demonstrated excellent efficacy in closing large gastrointestinal defects [55]. This reopenable, rotatable, through-the-scope clip features anchor prongs designed to securely grasp wound edges. Here, we describe a case in which we combined ESD of the GCF with closure using an OTS clip assisted by the Mantis clip, eliminating the need for a twin grasper and reducing costs.

BACKGROUND:Symptomatic gallstone disease is a common and burdensome condition, with early cholecystectomy recommended to prevent relapses. However, delayed cholecystectomies lack standardized prioritization criteria. This study aimed to identify determinants independently associated with shorter waiting times for delayed cholecystectomy, and to assess the alignment of current surgical prioritization with relapse predictors described in the previous RELAPSTONE study. METHODS:This was a post hoc analysis of the Spanish RELAPSTONE cohort, comprising patients admitted for a first episode of symptomatic gallstone disease between January 2018 and April 2020, who did not undergo cholecystectomy during the index hospital admission. The primary outcome was waiting time (in months) to delayed cholecystectomy. Linear regression models with β-coefficients were used to identify clinical factors associated with surgical delays (primary outcome of interest). Secondarily, the impact of relapse on prioritization was also evaluated. RESULTS:This study analysed 1508 patients of the 3016 included in the RELAPSTONE cohort. Median age was 68.2 (interquartile range 53.9-76.6) years; 51.4% were men. Median waiting time to delayed cholecystectomy was 4.5 (interquartile range 2.3-7.0) months. Initial presentation as acute cholecystitis (β = -2.2, P = 0.048) and multiple cholelithiasis (β = -0.6, P = 0.006) were linked to shorter waiting times, whereas older age (> 54 years; β = 0.8, P = 0.002), advanced liver disease (β = 2.4, P = 0.047), and relapse (β = 0.5, P = 0.036) were associated with longer delays, compared with their respective reference groups. Among 575 patients (38.1%) with relapse, time to delayed cholecystectomy did not differ by relapse type. Several known risk factors for relapse identified in previous RELAPSTONE analyses, including the performance of endoscopic sphincterotomy and leucocyte and alanine aminotransferase levels, did not influence prioritization. CONCLUSION:Determinants of surgical timing were not well aligned with previously identified predictors of relapse. These findings support the need for evidence-based triage strategies to improve timing and outcomes of delayed cholecystectomy.

BACKGROUND AND AIMS:Several endoscopic techniques are available for the closure of fistulas, but reported long-term efficacy is disappointing. Endoscopic submucosal dissection combined with endoscopic closure showed promising results. We evaluated the results of this combined technique in a larger number of consecutive patients. METHODS:Patients with GI fistulas, including those with previous failed treatment, were retrospectively included. During the procedure, injection and circumferential incision around the fistulous hole was performed, followed by dissection of the fistulous track as deep as possible, creating a mucosal flap. The flap was finally removed and the edges closed using several closure devices. The primary outcome was long-term (>3 months) success of fistula healing. Secondary outcomes included technical success, safety, and factors associated with success. To evaluate risk factors for long-term failure, patients treated in our previous descriptive study were included in the univariable analysis. RESULTS:We included 32 patients (66% refractory) in the present study. Technical success was 78%. In total, 28 of 32 (88%) patients completed >3 months follow-up. Among them, 43% (12/28) achieved long-term closure with 8 months median follow-up (IQR, 5-18). In treatment-naïve patients, technical success rate was 91% (10/11) and long-term closure was 78% (7/9). Adverse events occurred in 3 patients (9%). Risk factors for long-term failure were evaluated in 51 patients (23 previously treated in our first descriptive study and 28 patients with complete follow-up from the present evaluation). Age (P = .01), surgical (P = .007), or oncologic origin (P = .001) and previous treatment attempts (P = .007) were significantly associated with failure. CONCLUSIONS:Endoscopic submucosal dissection with closure is safe and effective to cure fistulas and could be considered part of the first-line treatment for treatment-naïve patients. In patients refractory to treatment, although of moderate efficacy, this technique could represent an alternative approach before salvage surgery.

An accurate histological diagnosis of colorectal cancer is essential for promptly establishing appropriate therapeutic management. Furthermore, nowadays larger samples are needed to evaluate immunological and genetic panels. For malignant lesions that cannot be removed endoscopically, the European Guidelines recommend taking six carefully targeted biopsies from the suspected cancer focus [1]. Despite advancements in endoscopic imaging, a retrospective study of 962 patients undergoing colorectal adenocarcinoma resection found that 29% (62/217) required repeat endoscopy due to sampling errors [2], leading to a 1.36-fold increase in time to surgery (95% CI 1.20–1.54, p<0.001) and higher healthcare costs. Choi et al. found that positive diagnosis rates for the first, second, and third biopsy specimens of advanced colorectal cancer were 78.1%, 87.5%, and 93.8%, respectively, with no significant increase from additional biopsies [3]. Reducing biopsy numbers by increasing targeted tissue sample size through cold snaring could enhance diagnostic sensitivity, minimize repeat procedures, and reduce pathologist workload.