Objective Ampullary neoplastic lesions can be resected by endoscopic papillectomy (EP) or transduodenal surgical ampullectomy (TSA) while pancreaticoduodenectomy is reserved for more advanced lesions. We present the largest retrospective comparative study analysing EP and TSA. Design Of all patients in the database, lesions with prior interventions, benign histology advanced malignancy (T2 and more), patients with hereditary syndromes and those undergoing pancreatoduodenectomy were excluded. All remaining cases as well as a subgroup of them, after propensity-matching (nearest-neighbour-method) based on age, gender, anthropometrics, comorbidities, size and histological subtype, were analysed. The median follow-up was 21 months (IQR 10-47) after the primary intervention. Primary outcomes were rates of complete resection (R0) and complications. Groups were compared by Fisher's exact or chi(2) test, Mann-Whitney-U-test and log-rank test for survival. Results Of 1673 patients in the database, 1422 underwent EP and 251 TSA. Of them, 23.2% were excluded for missing or inconclusive data and 19.8% of patients for prior interventions or hereditary syndromes. Final histology showed in 24.2% of EP and 14.8% of TSA patients a histology other than adenoma or adenocarcinoma while advanced cancers were recorded in 10.9% of EP and 36.6% of TSA patients. Finally, 569 EP and 63 TSA were included in the overall analysis, with a higher rate of more advanced cases and higher R0 resection rates in the TSA groups (90.5% vs 73.1%; p<0.01), with additional ablation in the EP group in 14.4%. Severe adverse event rates were 3.2% (TSA) vs 1.9% (EP). Recurrence after histological R0 resection was 16% (EP) vs 3.2% (TSA; p=0.01), and additional therapy for R1 resection was applied in 67% of the 159 cases. Propensity-score-based matching identified 62 pairs of EP/TSA patients with comparable baseline patient and lesion characteristics. The initial R0-rate was 72.6% (EP) compared with 90.3% (TSA, p=0.02) with recurrences found in 8% (EP) vs 3.2% (TSA; p=0.07); reinterventions were more frequent in the EP group. Overall survival was comparable. Conclusions The rate of patients with poor indications due to non-neoplastic disease or advanced cancer is still high for both EP and TSA; multiple retreatments were necessary for EP. Although EP can be considered an appropriate primary therapy for certain ampullary adenomas, case selection for both therapies (especially with regard to the best step-up approach) should be studied further.

Background The ideal treatment of epithelial neoplastic rectal lesions involving the dentate line is a controversial issue. Piecemeal endoscopic mucosal resection (EMR) is the most commonly used resection technique, but it is associated with high recurrence rates. Endoscopic submucosal dissection (ESD) has been shown to be safe and effective for the treatment of rectal lesions, but evidence is lacking concerning its application close to the dentate line. The aim of our study is to compare ESD and EMR for the treatment of epithelial rectal lesions involving the dentate line. Methods We identified all cases of endoscopic resections of rectal lesions involving the dentate line performed in two German high-volume centers between 2010 and 2022. Periinterventional and follow-up data were collected and retrospectively analyzed. Results We identified 68 ESDs and 62 EMRs meeting our inclusion criteria. ESD showed a significant advantage in en bloc resection rates (89.7% vs. 9.7%; P = 0.001) and complete resection rates (72.1% vs. 9.7%; P = 0.001). The overall curative resection rate was similar between both groups (ESD: 92.6%, EMR: 83.9%; P = 0.324), whereas in the subgroup of low-risk adenocarcinomas ESD was curative in 100% of the cases vs. 14% in the EMR group (P = 0.002). There was one local recurrence after ESD (1,5%) vs. 16 (25.8%) after EMR (P < 0.0001), and the EMR patients required an average of three further interventions. Conclusion ESD is superior to EMR for the treatment of epithelial rectal lesions involving the dentate line and should be considered the treatment of choice.

OBJECTIVES:The value of multidisciplinary tumor boards (MTBs) in the treatment of gastrointestinal cancer patients is well known. Most of the current evidence focuses on advanced cancer cases, whereas little is known about the effect of MTBs on early tumors, especially after endoscopic resection. The aim of our study is to evaluate the value of the MTB after endoscopic resection of malignant tumors of the gastrointestinal tract. METHODS:We retrospectively analyzed all endoscopically resected malignant tumors in our department between 2011 and 2019, focusing on the existence of an MDT recommendation after endoscopic resection, the MDT adherence to the current guidelines, and the implementation of the recommendation by the patients. RESULTS:We identified 198 patients fulfilling our inclusion criteria, of whom 168 (85%) were discussed in the MDT after endoscopic resection. In total, 155 of the recommendations (92%) were in accordance with the current guidelines, and 147 (88%) of them were implemented by the patients. The MDT discussion itself did not influence the overall survival, whereas the implementation of the MTB recommendation was associated with a significantly better prognosis. Deviations of the MDT recommendation from the guidelines had no effect on the overall survival. CONCLUSIONS:The discussion of endoscopically resected malignant tumors in the MTB is crucial for the treatment of patients with this type of cancer, since the implementation of the MTB recommendation, even if it deviates from the current guidelines, improves the prognosis.

Auch wenn breitgefächerte Maßnahmen zur Vermeidung von Komplikationen durch verbesserte Techniken, Training und viele andere Aktivitäten unternommen wurden, stellen postoperative und postinterventionelle Komplikationen weiterhin ein tägliches Problem der klinischen Medizin dar. Das Outcome der Patienten entscheidet sich nicht selten durch das Management der Komplikationen. Ihr Versagen („failure of rescue“) bzw. ihre Beherrschung wird zunehmend als entscheidend für das Ergebnis der Therapie angesehen. In diesem Artikel soll deshalb ein aktueller Überblick über das endoskopische Komplikationsmanagement am oberen und unteren Gastrointestinaltrakt gegeben werden. Es wird dargestellt, wann die Endoskopie zum Nachweis oder Ausschluss einer Komplikation eingesetzt werden kann. Die wichtigsten Therapieprinzipien werden in ihrer Indikation, ihren Leistungsgrenzen und ihrer Technik dargestellt.

Introduction Symptomatic anastomotic stricture is a rare but major complication after left-sided colorectal surgery. Hydraulic balloon dilatation is the first-line treatment in cases where the complication occurs, but 20% of patients present with refractory strictures after multiple sessions. Endoscopic stricturoplasty with the use of a linear stapler is a novel therapeutic alternative for those difficult cases.Materials and Methods We identified all patients in our department who underwent endoscopic stricturoplasty with a linear stapler between 2004 and 2022. The technical, periinterventional, and follow-up data of the patients were retrospectively analyzed.Results We identified nine patients who fulfilled our inclusion criteria. The procedure was technically possible in eight cases, whereas in one case, the anatomy of the anastomosis did not allow for a correct placement of the stapler. All patients with a technically successful procedure were relieved from their symptoms and could have their ostomy reversed. There was no periprocedural morbidity and mortality. Two patients presented with a recurrent stricture eight and 26 months after the initial stricturoplasty, and the procedure was successfully repeated in both cases.Conclusions Endoscopic stricturoplasty is a feasible, safe, and minimally invasive alternative for the treatment of refractory anastomotic strictures in the distal colon and rectum for patients with a suitable anatomy.

Background: Ampullary lesions are rare and can be locally treated either with endoscopic papillectomy or transduodenal surgical ampullectomy. Management of local recurrence after a first-line treatment has been poorly studied.Methods: Patients with a local recurrence of an ampullary lesion initially treated with endoscopic papillectomy or transduodenal surgical ampullectomy were retrospectively included from a multi -institutional database (58 centers) between 2005 and 2018.Results: A total of 103 patients were included, 21 (20.4%) treated with redo endoscopic papillectomy, 14 (13.6%) with transduodenal surgical ampullectomy, and 68 (66%) with pancreaticoduodenectomy. Redo endoscopic papillectomy had low morbidity with 4.8% (n = 1) severe to fatal complications and a R0 rate of 81% (n = 17). Transduodenal surgical ampullectomy and pancreaticoduodenectomy after a first pro-cedure had a higher morbidity with Clavien III and more complications, respectively, 28.6% (n = 4) and 25% (n = 17); R0 resection rates were 85.7% (n = 12) and 92.6% (n = 63), both without statistically significant difference compared to endoscopic papillectomy (P = .1 and 0.2). Pancreaticoduodenectomy had 4.4% (n = 2) mortality. No deaths were registered after transduodenal surgical ampullectomy or endoscopic papillectomy. Recurrences treated with pancreaticoduodenectomy were more likely to be adenocarcinomas (79.4%, n = 54 vs 21.4%, n = 3 for transduodenal surgical ampullectomy and 4.8%, n =1 for endoscopic papillectomy, P < .0001). Three-year overall survival and disease-free survival were comparable.Conclusion: Endoscopy is appropriate for noninvasive recurrences, with resection rate and survival outcomes comparable to surgery. Surgery applies more to invasive recurrences, with transduodenal surgical ampullectomy rather for carcinoma in situ and early cancers and pancreaticoduodenectomy for more advanced tumors.(c) 2022 Elsevier Inc. All rights reserved.

Die endoskopischen Methoden stellen heutzutage ein wertvolles Tool zur Behandlung postoperativer Komplikationen der hepatobiliopankreatischen und Thoraxchirurgie dar. Bei Gallenleckagen nach Cholezystektomie, Leberresektion oder Lebertransplantation ist die endoskopische Druckentlastung der Gallengänge die Therapie der Wahl. Postoperative Gallengangsstenosen können auch in den meisten Fällen erfolgreich endoskopisch durch Ballondilatation und Implantation unterschiedlicher Endoprothesen behandelt werden. Im Fall der Pankreasfisteln, insbesondere nach zentralen oder distalen Resektionen, kann die endoskopische Entlastung des Pankreasgangs viel zur zügigen Heilung beitragen. Zudem bietet die interventionelle Endosonographie eine wichtige therapeutische Option zur transgastralen Drainage postoperativer Flüssigkeitsansammlungen, die oft eine Pankreasfistel begleiten. Mehrere Behandlungsalternativen wurden auch zur bronchoskopischen Versorgung bronchopleuraler und tracheoösophagealer Fisteln beschrieben, die zur zügigen Linderung der Symptomatik und oft zum definitiven Verschluss der Fistel führen.

ZusammenfassungKomplikationen nach bariatrischer Chirurgie sind selten. Die meisten Komplikationen lassen sich endoskopisch oder mithilfe der Endoskopie therapieren. Das Seltene stellt jedoch im klinischen Alltag eine Herausforderung dar. Damit die Komplikationen bestmöglich versorgt werden und der Schaden für den einzelnen Patienten möglichst gering ist, bedarf es eines Komplikationsmanagements. Der Artikel gibt eine Übersicht über wesentliche Komplikationen und gängige endoskopische Therapieoptionen, mit dem Fokus auf aktuelle publizierte Therapiestrategien der letzten 5 Jahre. Der Artikel soll als Basis dienen für die Etablierung eines eigenen Komplikationsmanagements in den jeweiligen Kliniken.

BACKGROUND: Colonic wall injuries are the most feared adverse events of endoscopic resections among endoscopists. The implementation of endoscopic closure has offered a reliable way to treat such injuries and, thus, has decreased their overall morbidity and mortality. OBJECTIVES: The aim of our study is to assess the characteristics and outcomes of colonic wall injuries after endoscopic resection, focusing on the endoscopic treatment of these injuries. DESIGN: This was a retrospective cohort study. SETTINGS: Patients treated in the Central Endoscopy Unit of the Medical Centre Mannheim were included. PATIENTS: We retrospectively analyzed all patients who underwent endoscopic mucosal resection and snare polypectomy in our center between 2004 and 2019 and isolated the resection-related colonic wall injuries. These were divided into 3 groups: group A, endoscopically treated early colonic wall injuries; group B, nonendoscopically treated early colonic wall injuries; and group C, late perforations. MAIN OUTCOME MEASURES: Periprocedural factors and treatment outcomes were analyzed and compared among the 3 groups. RESULTS: Of 3782 endoscopic resections, we identified 177 cases of colonic wall injuries, of which 148 were identified and treated endoscopically (group A), 9 were identified during the procedure but could not be treated endoscopically (group B), and 20 were late perforations (group C). Endoscopic treatment with use of clips had a technical success rate of 94.3%, while the clinical success rate of technically complete endoscopic closure was 92.6%. Twenty-two percent of all colonic wall injuries required surgical treatment; the type and outcomes of surgery were similar in all groups. Overall hospital stay was significantly lower in group A. LIMITATIONS: The main limitation of the study is its retrospective design. CONCLUSIONS: Endoscopic closure with the use of clips is a safe and feasible treatment for intraprocedurally identified colonic wall injuries and is associated with significantly decreased necessity of surgery, morbidity, and hospital stay. See Video Abstract at http://links.lww.com/DCR/B755. LESIONES DE PARED COLÓNICA POSTERIOR A RESECCIÓN ENDOSCÓPICA: ¿ES AÚN UNA COMPLICACIÓN IMPORTANTE? ANÁLISIS RETROSPECTIVO DE 3782 RESECCIONES ENDOSCÓPICAS ANTECEDENTES: Las lesiones de la pared del colon son los eventos adversos más temidos por los endoscopistas durante las resecciones endoscópicas. La implementación del cierre endoscópico ha ofrecido una forma confiable de tratar tales lesiones y, por lo tanto, disminuyendo su morbilidad y mortalidad general. OBJETIVOS: El objetivo de nuestro estudio es evaluar las características y resultados de las lesiones de la pared colónica posterior a la resección endoscópica, centrándose en su tratamiento endoscópico. DISEÑO: Es un estudio de cohorte retrospectivo. ENTORNO CLÍNICO: Se incluyeron pacientes tratados en la Unidad Central de Endoscopia del Centro Médico de Mannheim. PACIENTES: Se analizaron retrospectivamente todos los pacientes sometidos a resección endoscópica de la mucosa y polipectomía en asa en nuestro centro entre 2004 y 2019, seleccionando las lesiones de la pared colónica relacionadas a la resección. Estas se dividieron en tres grupos: Grupo A: lesiones tempranas de la pared colónica tratadas endoscópicamente; Grupo B: lesiones tempranas de la pared colónica no tratadas endoscópicamente; y Grupo C: perforaciones tardías. PRINCIPALES MEDIDAS DE VALORACION: Se analizaron y compararon los factores relacionados al procedimiento y los resultados del tratamiento entre los tres grupos. RESULTADOS: De 3782 resecciones endoscópicas identificamos 177 casos de lesiones de la pared colónica, de los cuales 148 fueron identificados y tratados endoscópicamente (Grupo A), 9 fueron identificados durante el procedimiento pero no pudieron ser tratados endoscópicamente (Grupo B) y 20 fueron perforaciones tardías. (Grupo C). El tratamiento endoscópico con el uso de clips tuvo una tasa de éxito técnico del 94,3%, mientras que la tasa de éxito clínico del cierre endoscópico técnicamente completo fue del 92,6%. El veintidós por ciento de todas las lesiones de la pared colónica requirieron tratamiento quirúrgico; el tipo y los resultados de la cirugía fueron los mismos en todos los grupos. La estancia hospitalaria global fue significativamente menor en el grupo A. LIMITACIONES: La principal limitación del estudio es su diseño retrospectivo. CONCLUSIONES: El cierre endoscópico con el uso de clips es un tratamiento seguro y factible para las lesiones de la pared colónica identificadas durante el procedimiento y se asocia con una disminución significativa de la necesidad de cirugía, morbilidad y de estancia hospitalaria. Consulte Video Resumen en http://links.lww.com/DCR/B755.

Purpose Management of colorectal anastomotic leakage (AL) is patient-oriented and requires an interdisciplinary approach. We analyzed the management of AL according to its severity and presence of ostomy and proposed a therapy algorithm. Methods We identified all patients who underwent colorectal surgery and developed an AL in our clinic between 2012 and 2017. The management of AL was retrospectively analyzed according to the severity grade: asymptomatic (A), requesting interventional or antibiotic therapy (B), undergoing re-operation (C). The groups were compared according to the leakage characteristics, presence of ostomy, and patient clinical conditions. Results We identified 784 consecutive patients meeting the inclusion criteria. Of these, 10.8% experienced an AL (A = 18%, B = 48%, and C = 34%). The rate of successful ostomy closure was 100% (A), 68% (B), and 62% (C), respectively. Within group B, 91% of the patients were treated solely by endoscopic negative pressure therapy (ENPT), whereas 37% of the patients within group C required ENPT in addition to surgery. Seven cases within group B (17%) required no protective ostomy (nOB) during ENPT which was itself shorter and required less cycles in comparison to group B with ostomy (OB) ( p = 0.017 and 0.111, respectively). Moreover, the leakage distance to anal verge was higher in the OB subgroup ( p < 0.001). Conclusion ENPT for the treatment of colorectal AL is efficient in combination with operative revision or protective ostomy. In selected patients, it is feasible also in the absence of a protective ostomy.

Die Laparoscopic Sleeve Gastrectomy (LSG) hat sich zum häufigsten Standardeingriff der metabolischen Chirurgie entwickelt und verbindet eine hohe Effektivität hinsichtlich der Adipositas und ihrer Folgeerkrankungen mit sehr geringer Morbidität. Dennoch wird ihre Indikation erst ab einem BMI von 40 oder bei ausgeprägter Komorbidität ab BMI 35 gesehen, also in einem eigentlich dekompensierten Endstadium des metabolischen Syndroms. Können endoskopische Verfahren zur Magenverkleinerung hier eine Alternative, insbesondere bei früheren Erkrankungsstadien bieten? Dieser Artikel beschreibt die aktuelle Situation.

Frage 1: Was ist die beste Methode für die Beobachtung von Patienten mit chronisch-entzündlicher Darmerkrankung (CED)? Sonografie, Endoskopie, Labor oder einfach klinisch? Böcker: Das beste Mittel für die Tumor-Surveillance ist die Endoskopie, für die Überwachung auf Strikturen sind es die klinischen Symptome, für die Beobachtung des (distalen) Entzündungsgeschehens ist es das Calprotectin im Stuhl. Ehehalt: Der Goldstandard ist wohl die Endoskopie, aus praktischen Gründen liegt aber die klinische Untersuchung in Verbindung mit Laborwerten vorn. Götz: Tumor-Surveillance: Endoskopie; Ansprechen auf eine Behandlung: klinisch; Labor: häufig; Sonografie: wird geprüft, wahrscheinlich gut (Darmwanddicke, Limberg-Score); Endoskopie: optimal, aber invasiv und besonderen Situationen vorbehalten. Hasselblatt: Der beste Ansatz zur routinemäßigen Beobachtung von Patienten mit CED ist klinisch in Kombination mit Calprotectin (Wert sollte <250 sein). Bei Symptomen nehmen wir Ultraschall hinzu, Endoskopie wenn nötig (oder indiziert; z.B. zur Tumor-Surveillance und wenn der Befund die Therapieentscheidung beeinflusst), gegebenenfalls auch MRT. Kreis: Jede davon in angemessenen Intervallen. Kroesen: Das hängt vom Zustand des jeweiligen Patienten ab. Im Allgemeinen sind Sonografie und klinische Untersuchung ausreichend. Wenn der Patient plötzlich schlechter wird oder zunehmend stenotische Beschwerden hat, kann eine Endoskopie erforderlich werden, vor allem wenn eine Operation oder endoskopische Dilatation als Behandlungsoption näherrückt.

Fremdkörper im Gastrointestinaltrakt und deren Therapie sind eine häufige Herausforderung in der Endoskopie. Der Vielfalt möglicher Fremdkörper sind dabei kaum Grenzen gesetzt und auch erfahrene Endoskopiker können nach Jahren überrascht werden, was Menschen sich alles zuführen können. Dieser Beitrag soll allgemeingültige Überlegungen und Tricks im Umgang mit Fremdkörpern im Gastrointestinaltrakt aufzeigen.

Background: Pancreatic pseudocysts (PPC) are collections of fluid encapsulated within a well-defined inflammatory wall that develop during pancreatic inflammation. Internal drainage represents the standard of care in lesions. Only limited data are available on long-term results. Thus, the aim of the present study was to analyse the long-term outcome after endoscopic drainage of PPC. Methods: Patient data were retrospectively collected. We assessed the clinical short-term outcome within 30 days after initial drainage procedure, medium-term outcome within 6 months after initial drainage procedure and long-term outcome. We performed statistical analysis to identify possible risk factors for recurrence of PPC. Results: We identified 51 patients with initially successful endoscopic drainage of the PPC. Among this cohort, 43 patients were available for assessment of medium-term results. In 82.9% of these 43 patients the drainage could be removed after successful treatment of the PPC. Thirty patients were available for long term follow-up with a mean observation period of 42.2 months. 7 of these had recurrent PPC. Approximately half of the recurrent cysts arose in different anatomical regions and most patients with recurrence had chronic pancreatitis. Conclusion: For most patients endoscopic drainage of PPC is sufficient. However, recurrences occur. Because most of these occur in chronic pancreatitis and different anatomical locations we conclude that these might be new PPC and not persistence of old PPC.

The prevalence of advanced dysplasia and synchronous lesions is particularly high in patients with large, flat colorectal polyps. However, the impact of lifestyle on the development of such polyps is poorly investigated. Hence, this study aims to identify associations between behavioral factors and the occurrence of large, flat colorectal polyps.