Introduction

Endoscopy is the first-line approach for managing Zenker's Diverticulum (ZD). Various endoscopic techniques, each with its own advantages and limitations, have been described. We have proposed a new technique, which we have named Submucosal Injection-Guided septomyotomy (SING technique).

Aims & Methods

The performance of SING technique was evaluated in a prospective observational cohort of patients with ZD who underwent the procedure at two Italian hospitals: San Raffaele Hospital (Milan, Italy) and San Giovanni Bosco Hospital (Turin, Italy).
SING technique involves a classic septotomy, which consists of a mucosal incision with a Hook-Knife in the middle of the septum and a cricopharyngeal myotomy for all the length of the Zenker's Diverticulum and beyond 10 mm into the esophageal proper muscular layer. The novelty of the technique lies in the submucosal injection during the septomyotomy on both the esophageal and diverticular sides, which helps to better delineate the muscular layer and guide the complete myotomy, without the need for bilateral submucosal tunnelling.
Clinical success (CS) was defined as a Dakkak and Bennet Dysphagia Score (DBDS) of ≤1 and a Kothari-Haber Score (KHS) of <2 at 3 months. Recurrence was defined as an increase in DBDS of >1 after achieving CS or a KHS of ≥2 after CS. Follow-up included clinical evaluations at 3 and 6 months, and then annually. Adverse Events (AEs) are classified according to the AGREE Classification.

Results

42 patients with ZD underwent SING technique between March 2021 and January 2024 (median age 74 [IQR 67-80], 66.7% males, BMI 24.6 [IQR 21-27]). The median diverticula depth was 30mm (IQR 25-45) with a median septum length of 20mm (IQR 14-30). Median KHS at diagnosis was 4 (IQR 4-6), dysphagia for solids (42.9%) was the most common symptom, with a median symptom duration of 12 months (IQR 6-24). While a technical success rate was observed in all cases (42/42, 100%), a clinical success rate was observed in 40/42 patients (95.2%). In the 2/42 (4.8%) cases of clinical failure, endoscopic evaluation revealed the presence of a minimal residual muscular septum successfully treated with septomyotomy. Median procedural time was 34 minutes (IQR 29-60), with a hospital stay of 2 days (IQR 2-2). No AEs were recorded. After a median follow-up of 370 days (IQR 297-747), no cases of symptom recurrence were recorded.

Conclusion

SING technique is a safe and effective technique for the endoscopic treatment of ZD. It improves and enhances the efficacy of traditional endoscopic septotomy and can also be utilized as rescue therapy.

Introduction

Splanchnic vein thrombosis (SVT) is a local complication of acute pancreatitis (AP) that may lead to subsequent complications such as portal hypertension, gastrointestinal bleeding, and mesenteric ischemia.^1,2 Despite its clinical significance, there is limited data in the literature concerning the temporal development and associated risk factors of SVT.

Aims & Methods

Our aim was to understand the time course and risk factors of SVT in the early phase of AP. To identify relevant studies we conducted a systematic search across four major medical databases (Embase, MEDLINE via PubMed, Scopus, and Cochrane Central Register of Controlled Trials) on 27th of October 2022. We included studies that employed appropriate imaging techniques in adult patients with AP, reported SVT data from the early phase of AP, and provided reliable information about the timing of imaging relative to AP symptom onset or hospital admission. We excluded studies that reported data on patients with a recent history of malignant disease or recent surgical procedures. We calculated the proportion of patients affected by SVT with 95% confidence intervals (CI). We conducted subgroup analyses based on diagnostic timing and disease characteristics. To assess the risk of bias we used the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies and the GRADEpro tool to determine the level of evidence. The protocol for this method was registered prospectively in the PROSPERO database, with registration number CRD42022367578.

Results

Data from 14 eligible studies and 1,951 patients was pooled; the proportion of patients with SVT in the early phase of AP (within 11 days after symptom onset or 5 days after hospital admission) was 0.13 (CI 0.07-0.23). The occurrence was lowest 0-3 days after symptom onset at 0.06 (CI 0.03-0.1), it increased to 0.23 (CI 0.16-0.31) between 3-11 days. Disease factors influencing SVT occurrence were severity (mild: 0.14 (CI 0.04-0.39), moderate: 0.23 (CI 0.09-0.47), severe: 0.31 (CI 0.15-0.54), p=0.21), etiology (alcoholic 0.31 (CI 0.13-0.58), biliary 0.12 (CI 0.04-0.3), p=0.03), and pancreatic necrosis (absent 0.10 (CI 0.04-0.25), under 30% 0.25 (CI 0.1-0.5), over 30% 0.55 (CI 0.29-0.78), p= 0.01).

Conclusion

One in eight patients develops SVT in the early phase of AP. Alcoholic etiology and pancreatic necrosis increase the risk of SVT. In addition, this risk seems to increase with the duration of AP; therefore, looking for and diagnosing SVT with imaging is important in the management of AP.

References

1. Nawacki L, Matykiewicz J, Stochmal E, Gluszek S. Splanchnic Vein Thrombosis in Acute Pancreatitis and Its Consequences. Clin Appl Thromb Hemost. 2021;27.
2. Valeriani E, Riva N, Di Nisio M, Ageno W. Splanchnic Vein Thrombosis: Current Perspectives. Vascular Health and Risk Management. 2019;15.

Clinical Case Summary

Introduction: Acute pancreatitis (AP) is an inflammatory condition of the pancreas that manifests with abdominal pain and elevation in serum pancreatic enzymes. Gastric retention following AP can occur due to gastric hypomotility or gastric outlet obstruction (GOO). GOO in AP is related to gastric outlet gastrointestinal edema or compression by necrotic/fluid collections.
Case Description/Methods: A 26-year-old female patient presented to our hospital with upper abdominal pain for 3 days. Her laboratory investigations showed elevated LFTs of a cholestatic pattern. Her MRCP revealed mild prominence of the CBD with distal tapering. She underwent ERCP with removal of a small CBD stone and CBD stent placement.
Afterward, the patient complained of constant epigastric and periumbilical pain associated with fever. Pancreatic enzymes were elevated, and CT abdomen was notable for prominent pancreas with peripancreatic stranding and fluid confirming the development of post-ERCP pancreatitis. She was managed with fluids and morphine for pain management. Ten days later, she reported left epigastric and upper abdominal pain that was different from the epigastric pain that followed the procedure. The pain was associated with nausea, recurrent vomiting and constipation. Repeated CT abdomen with contrast demonstrated noticeable extensive inflammatory changes within the region of the pancreatic head and newly developed significant gastric and proximal duodenal dilatation. Her clinical condition improved in the following days with conservative treatment with improvement in the abdominal pain and better tolerance to the oral diet.
Discussion: Our patient had early-onset GOO as a complication of AP, probably due to gastric outlet gastrointestinal edema, that resolved with conservative treatment. This is a complication that is easy to miss, especially in the early phase of the disease (< 4 weeks) when the patient’s pain and vomiting can be attributed to the AP itself.

Introduction

Complete excision of upper gastrointestinal sub-epithelial lesions (SELs) eliminates diagnostic uncertainty, obviates the need for surveillance and may be necessary for definitive diagnosis and management. Current guidelines lack precision and cohesion, and surgery is associated with significant morbidity. Herein, we describe and report on the outcomes of our SEL algorithm for endoscopic (SAFE) resection.

Aims & Methods

SELs were enrolled prospectively over 115 months until March 2023. All underwent axial (CT) imaging and endoscopic-ultrasonography (EUS) to exclude a large exophytic component or invasion into local structures, and assess for muscularis propria involvement.

Results

106 SELs were resected (mean age 60.6±13.4, 51.9% male; 41 oesophageal, 65 gastric). Oesophageal SELs underwent ESD (n=22) or STER if MP involvement was suspected (n=19). Gastric SELs underwent STER (n=6 at cardia), ESD (n=47) or exposing-EFTR (n=12). Technical success was 97.6% and 92.3% respectively. Five (7.7%) were completed laparoscopically due to deep and broad full-thickness involvement. Five (7.7%) required laparoscopic gastrotomy and surgical retrieval after successful resection and closure due to a large lesion size (mean 47 mm). There was no delayed bleeding, perforation or recurrence at a median of 13 months.

Conclusion

Upper GI SELs are effectively and safely treated by endoscopic resection. The SAFE approach provides a framework that facilitates structured decision-making. Oesophageal SELs suspected to involve the MP should undergo STER. Gastric SELs can be best managed by ESD with a view to proceed to exposing-EFTR. A laparoscopic UGI surgeon should be available in case surgical retrieval of the specimen or laparoscopic completion is required.

Disclosure

Michael J. Bourke: Research Support: Olympus, Cook Medical, Boston Scientific.

Introduction

Solid-pseudopapillary neoplasm (SPN) is a rare tumor of low malignancy that occurs predominantly in young females. Imaging of SPN is often described as a well-defined and heterogeneous tumor with calcifications or cysts, otherwise small size SPN often shows a homogeneously solid tumor. However, the differential diagnosis between SPN and other cystic tumors is often difficult due to the variety of imaging findings. In this report, we describe the clinical features and preoperative diagnosis of SPN we experienced at our hospital.

Aims & Methods

We studied 18 cases of SPN that were pathologically diagnosed by surgical resection at our hospital between 1997 and 2022.

Results

There were 12 female and 6 male patients, with a median age of 39.5 years (range: 9-67) and a median tumor size of 23 mm (range: 9-66). The tumor location was in the pancreatic head in 4 cases, body in 6 cases, and tail in 8 cases. The median follow-up period was 89.5 months (range: 8-265), and recurrence-free survival was achieved in all cases during the follow-up period. The tumors were incidentally detected in 15 cases during health check-ups (mainly by ultrasonography) or other medical examinations, while the other 3 cases were detected due to subjective symptoms that were thought to be caused by SPN. SPN could be diagnosed by contrast-enhanced CT in 10 of 18 cases (56%) and by EUS in 7 of 12 cases (58%). Contrast-enhanced CT showed enhancing mass in 10 cases, cystic component in 9 cases (50%), and calcification in 8 cases (44%). Among the 8 cases in which SPN could not be diagnosed by contrast-enhanced CT, EUS was performed in 7 cases, and we could diagnose SPN in 2 cases. Both cases had small lesions of less than 13 mm without cystic components, which made the differentiation from other tumors difficult on contrast-enhanced CT, however EUS showed well-circumscribed, well-defined, and homogeneously hypoechogenic tumors. MRI was performed in 12 cases, and could diagnose SPN in 5 cases, but MRI did not improve the diagnostic accuracy compared to contrast-enhanced CT. The diagnostic accuracy of EUS-guided fine needle aspiration (EUS-FNA) was 89% (8/9 cases). There were 5 cases in which SPN could not be diagnosed preoperatively. Among them, 3 cases had small tumor sizes (12-16 mm), and 4 cases lacked calcification, making it difficult to differentiate them from neuroendocrine tumors or solid-cystic neoplasms.

Conclusion

Most cases of SPN are detected incidentally, and regular abdominal ultrasonography during medical check-ups is important for early detection. Diagnosis can be more difficult in cases with small tumor diameter, and no cystic component or calcification. However adding EUS to contrast-enhanced CT imaging may improve accuracy. Furthermore, EUS-FNA contributes to preoperative diagnosis with a high diagnostic accuracy.