Aims Endoscopic submucosal dissection (ESD) constitutes the standard of care for local excision and staging of early rectal cancer. Patients with deep submucosal invasion into the mid-lower third of the submucosa (pT1b-SM2,3) or the muscle layer (pT2), are currently diagnosed with a non-curative resection and additional surgery protrudes as the most suitable approach according to the present guidelines. This study aimed to evaluate the efficacy of adjuvant radiotherapy and/or chemotherapy following endoscopic resection for reducing recurrence after local resection in patients diagnosed with deeply infiltrative rectal polyps unwilling or unsuitable for additional surgical resection.

Aims Duodenal neuroendocrine tumors (dNET) are rare tumors of the small intestine and are often found as an incidental finding of a subepithelial lesion during endoscopy. The Full-Thickness Resection Device (FTRD) enables endoscopic full-thickness resection of epithelial and subepithelial lesions. Endoscopic mucosa resection (EMR) has a low R0 resection rate for this indication, while endoscopic submucosal dissection (ESD) is associated with a higher rate of adverse events.

Background: Resected rectal polyps with deep invasion into the submucosa (pT1b-sm2,3) or the muscle layer (pT2) are currently confronted with surgery due to non-curative resection. Aims: We evaluated the efficacy, safety, and locoregional control of adjuvant radiotherapy (RT) and/or chemotherapy (CT) following endoscopic KAR (knife-assisted resection) in patients with invasive early rectal cancers who are unwilling or unsuitable for additional surgical resection. Methods: Fifty-one patients with early rectal cancers, pT1b or pT2, underwent post-resection adjuvant RT and/or CT in 15 centers worldwide. “En bloc” macroscopic resection, R0 resection, recurrence rate, and adverse events following resection and adjuvant therapy were recorded in a multicenter retrospective cohort study. Results: Diagnostic staging (38/51, 75%) was the main reason for ELE. Macroscopic “en bloc” resection was demonstrated in 50/51 (98%), with an average follow-up of 20.6 months. Endoscopic recurrence occurred in 7/51 (13.7%) of patients, with mean time for diagnosis of recurrence at 8.9 months. Adjuvant therapy consisted of RT in 49.0% (25/51), CT in 11.8% (6/51), and combined CRT in 39.2% (20/51) of the cases. Perforation, severe post-procedural bleeding, and incontinence were the most frequent complications. The absence of superficial ulceration was associated with macroscopic complete resection, while the lesions with lower budding stage, clear lateral margins, lesion size < 40 mm, and needle-type knife used were associated with less endoscopic recurrencies. Conclusions: Our data investigated adjuvant RT and/or CT after endoscopic KAR of infiltrative rectal cancers (pT1bsm2,3-pT2) as being safe and effective for locoregional control and providing a non-surgical treatment option for patients with a non-curative resection.

OBJECTIVES:Data of long-term follow up for large non pedunculated colorectal polyps (LNPCPs) ≥4 cm removed with piecemeal wide field endoscopic mucosal resection (PWF-EMR) are limited. We primarily evaluated the recurrence rates and secondarily the rates of post colonoscopic polypectomy colorectal cancer (PCPCRC) on a long-term basis. METHODS:We retrospectively reviewed a prospectively-stored electronic database of all patients who underwent PWF-EMR for LNPCPs at the Venizeleion General Hospital, between 2009 and 2020. Eligible patients were those with LNPCPs ≥4 cm, deemed completely removed by endoscopic means and followed-up for a minimum of 36 months with at least two surveillance colonoscopies, the first one (SC1) (4-6) months after the initial PWF-EMR procedure and the second one (SC2) after (12-18) months. In 2023, all cases were checked for PCPCRC development. RESULTS:Residual/early recurrent tissue was detected in 44 (31 %) cases among the 142 (82 males, 60 females) assessed during SC1. Late recurrent tissue was detected in 9 (6.6 %) cases among the 137 surveyed during SC2. Investigation did not reveal any case of PCPCRC . CONCLUSIONS:This historical cohort shows that the PWF-EMR for LNPCPs ≥4 cm is a safe and definitive removal method while it is not associated with the appearance of PCPCRC.

Background:Hybrid approaches combining endoscopic full-thickness resection (EFTR) with conventional techniques (endoscopic mucosal resection [EMR], endoscopic submucosal dissection [ESD]) have enabled the resection of difficult fibrotic colorectal adenomas exhibiting a "non-lifting" sign, and polyps in difficult positions. We present our cohort treated with either EMR+EFTR or ESD+EFTR as salvage hybrid endoscopic approaches for complex colorectal polyps not amenable to conventional techniques. Methods:Retrospective analysis included technical success, histological confirmation of margin-free resection, assessment of adverse events and follow up with histological assessment. All patients underwent follow-up endoscopy at least 6 and 12 months post-resection. Results:Fourteen patients underwent hybrid EFTR procedures (11 EMR+EFTR and 3 ESD+EFTR). Technical success was achieved in all cases where the full-thickness resection device (FTRD) was advanced to the site of the resection (100%). In 2 cases, the FTRD system could not be passed through the sigmoid colon because of severe chronic diverticulitis, subsequent fibrosis and stiffness. The mean lesion size in the EMR+EFTR group (41.7 mm; range 20-50 mm) was larger than the ESD+EFTR group (31.7 mm; range 30-35 mm). Six patients (42.9%) were histologically diagnosed with T1 carcinoma. The mean duration of hospitalization was 1.4 days. Follow-up endoscopy was available in all patients and no recurrence was observed with histological confirmation during a mean follow-up period of 15.4 months. Conclusion:Hybrid procedures appear to be safe and effective treatments for complex colorectal lesions not amenable to EMR, ESD or EFTR alone, because of the lesion size, positive non-lifting sign, and difficult positions.

1:  ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2:  ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3:  ESGE recommends CSP, to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of small polyps (6-9 mm).Strong recommendation, high quality of evidence. 4:  ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19 mm in size.Strong recommendation, high quality of evidence. 5:  ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6:  ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7:  Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8:  ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9:  ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10:  ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11:  ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.

Aims Gastric IFPs are benign tumours which represent about 0.1% of gastric polyps. They may be found incidentally during gastroscopy or they can be the underlying cause of anemia or upper gastrointestinal bleeding. Endoscopically, they appear as submucosal lesions. For this reason, endoscopic ultrasound (EUS) is an important diagnostic modality because it can distinguish them from other entities. In this study we present a retrospective analysis of the diagnosis and treatment of all the IFPs in our center.

Abstract Background Crohn’s disease can involve any segment of the gastrointestinal tract, with terminal ileum being the most common affected part. The wireless or video capsule endoscopy (VCE) is a valuable diagnostic tool in detecting lesions in the small bowel beyond terminal ileum. The findings of the procedure in combination with other clinical, endoscopic and laboratory factors can determine the therapeutic plan. Herein, we analyzed the findings of VCE in patients with suspicious or definite Crohn’s disease, and assessed its contribution to the therapeutic plan. Methods We evaluated these parameters in a retrospective analysis of 127 patients who underwent wireless capsule endoscopy in our department since June 2020. Results 49/127 patients (51% male) were included in the study. The mean age was 40.24 years (SD ±14.30, IQR= 73–15). The majority of them (93.9 %) presented with a newly diagnosed Crohn’s disease or terminal ileitis. The VCE examination was performed to detect any other lesions in the small bowel. 6.1% had chronic diarrhea without endoscopic findings. 57.1% had findings of Crohn’s disease across the entire small bowel, 26.6% had sparse ulcers in the terminal ileum. In 12.2% multiple aphthous ulcers and edema were found in the terminal ileum and 4.1% had no findings. After VCE examination, initiation of treatment was considered in 57.1%. Magnetic enterography (MRE) was performed in 24.5% of the patients. VCE showed more extended lesions in the small bowel compared to MRE which showed non-specific terminal ileitis up to 15 cm in all patients. Conclusion In patients with mild terminal ileitis wireless capsule endoscopy reveals extended lesions in the small bowel leading to adjustments in the therapeutic plan. In patients with newly diagnosed or suspected Crohn’s disease, VCE can contribute to the assessment of the severity and location of the lesions as well as to the therapeutic plan.

Geniko Nosokomeio Benizeleio, Greece.

Aims Hybrid approaches of full-thickness resection device (FTRD; Ovesco Endoscopy,Tuebingen, Germany) and conventional techniques (EMR,ESD) have enabled the removal of difficult fibrotic adenomas with a “non-lifting” sign. We present a cohort of 10 patients treated with EMR+FTRD or ESD+FTRD as rescue hybrid endoscopic techniques for difficult colorectal polyps.

It has been a long time since conventional endoscopic mucosal resection (C-EMR) was launched as a procedure of choice for the treatment of nonpedunculated colorectal polyps; however, for lesions of > 20 mm, piecemeal EMR has been associated with significant incomplete resection rates. The sequence from incomplete resection to colon cancer is well documented in the literature. Therefore, techniques that increase the rate of en bloc R0 resection with EMR are of the utmost importance. To this end, modified EMR techniques such as precutting EMR or anchoring EMR (A-EMR) have been proposed. A-EMR was first described in the last decade [1] [2], but what is this technique and what is its merit? A small incision is created with the tip of the snare in the submucosa of the mucosal area surrounding the polyp. Subsequently, the snare tip is anchored in the defect, with the aim of both preventing slippage of the snare and widening the diameter of the open snare.

Text Several reports support the use of endoscopic intermuscular dissection (EID) instead of endoscopic submucosal dissection (ESD) for the removal of deeply invasive rectal submucosal cancers. The resection plane into the intermuscular space, the space between the longitudinal (external) and circular (internal) muscle layer, provides a radical removal for rectal invasive cancers. Furthermore, the technique offers the potential for dissection of scarred and severe fibrotic lesions in the rectum by cutting deeper and perform a partial myectomy avoiding the narrow submucosal space. We would like to present our case series with 10 EIDs both for deeply invasive rectal cancers and benign rectal lesions.

Administration of sedation by non-anesthesiologists during gastrointestinal endoscopy remains highly controversial in Greece. The aim of this set of 16 position statements prepared by experts in the field on behalf of the Hellenic Society of Gastroenterology is to aid gastroenterologists in their everyday clinical practice and provide evidence for the best use of drugs for the sedation of patients who undergo an endoscopy. The statements address issues such as the level of sedation required, the best drugs used, their mode of action, their side-effects and possible ways to counter their action, and were adopted if at least 80% of all participants agreed upon them.

Background:Stone recurrence is a significant complication following endoscopic bile duct clearance. Endoscopic papillary large-balloon dilation (EPLBD) with biliary sphincterotomy (EBS) has shown satisfactory results in preventing recurrence of "large" common bile duct stones (CBDS). However, data on outcomes after EPLBD+EBS for CBDS ≤12 mm remain scarce. The present study prospectively evaluated the mid- and long-term efficacy of EPLBD+EBS for CBDS recurrence among this group of patients.Methods:Consecutive patients with CBDS ranging from 8-12 mm, treated with EPLBD+EBS from June 2018 through June 2020, were prospectively followed-up for at least 36 months. CBDS recurrence was defined as recurrent stones confirmed by endoscopic retrograde cholangiopancreatography (ERCP) during the follow-up period.Results:Overall, 72 patients (mean age: 67 years, 52.8% male) were included, of whom 22 (30.5%) had multiple (≥3) CBDS, 23 (31.9%) had a history of cholecystectomy, 13 (18.1%) had a periampullary diverticulum and 22 (30.5%) had a previous EBS. The mean CBD diameter was 11.6±1 mm, while a tapered duct was noted in 7 (9.7%). Post-procedural bleeding and cholangitis occurred in 1 and 2 cases respectively. No cases of perforation and post-ERCP pancreatitis were observed. During a mean follow up of 46.4±6.2 months (range 37-60), no mid-term recurrence was observed, whereas CBDS recurred in 2/72 (2.7%) in the long term.Conclusions:EPLBD+EBS in patients with CBDS ≤12 mm was associated with a very low rate of mid- and long-term CBDS recurrence. Our results need to be further investigated with randomized controlled trials.

In the current era of screening colonoscopy and increasing incidence of early rectal cancer, interventional endoscopy moves toward resections in deeper planes than the submucosal layer. Several reports support the use of endoscopic intermuscular dissection (EID) instead of endoscopic submucosal dissection (ESD) for the removal of deeply invasive rectal submucosal cancers. The resection plane into the intermuscular space, the space between the longitudinal (external) and circular (internal) muscle layer, allows radical removal of rectal invasive submucosal cancers. Furthermore, the technique offers the potential for dissection of scarred and severe fibrotic lesions in the rectum by cutting deeper and performing a partial myectomy avoiding the narrow submucosal space. We present 23 cases of EIDs both for deeply invasive rectal cancers and benign rectal lesions. This is the first report in the literature of EID resections for malignant and benign disease, including cases of severely fibrotic rectal lesions.

Aims Given the risks of endoscopy and transmitting the virus, the management of patients with COVID-19 pneumonia and upper gastrointestinal bleeding (UGB) is challenging. We evaluated 3 risk scoring systems for assessing the need for endoscopic treatment in patients with COVID-19 pneumonia and UGB.

Aims Hereditary polyposis syndromes are associated with an increased risk of colorectal cancer (CRC). Adenomatous polyps are present in familial adenomatous polyposis (FAP), MUTYH-associated polyposis (MAP) and NTHL1-associated syndrome. Hamartomatous polyps are developed in Peutz-Jeghers and juvenile polyposis syndrome. The aim of this study was to investigate the phenotype and mutation spectrum of these syndromes among Cretan population.