Introduction

Early gastric cancer (EGC) refers to adenocarcinoma confined to the mucosa or submucosa, regardless of lymph node status. It is increasingly detected due to the widespread implementation of upper gastrointestinal endoscopy, particularly in East Asia. For intramucosal EGC (T1a), endoscopic resection such as endoscopic submucosal dissection (ESD) has been established as the standard of care, given its low risk of lymph node metastasis (LNM) and favorable long-term outcomes. However, the management of submucosal invasive EGC (T1b) remains controversial. The Japan Gastroenterological Endoscopy Society (JGES) recommends additional surgical resection with lymphadenectomy following ESD if pathological evaluation indicates T1b invasion, due to the significantly increased LNM risk. Nonetheless, many patients who undergo surgery for T1b EGC are ultimately found to be node-negative, raising concerns regarding overtreatment and its associated morbidity. This study aimed to evaluate real-world data from a tertiary center in Taiwan to clarify the necessity of additional surgical intervention after ESD in T1b cases.

Aims & Methods

This retrospective cohort study analyzed data from patients diagnosed with EGC between January 2011 and December 2022 at Kaohsiung Chang Gung Memorial Hospital. Inclusion criteria were histologically confirmed Tis, T1a, or T1b gastric adenocarcinoma treated with either ESD or surgical resection. Patients with gastrointestinal stromal tumors, neuroendocrine neoplasms, or advanced-stage disease were excluded. Depth of invasion was evaluated preoperatively using endoscopic ultrasonography (EUS), and pathological staging was confirmed on resected specimens. Patients in the ESD group with submucosal invasion (T1b) were further assessed for curative resection status based on en bloc resection, margin negativity, and absence of lymphovascular invasion. Those with non-curative ESD were referred for additional gastrectomy and lymph node dissection. LNM rates and nodal staging were analyzed based on surgical pathology.

Results

A total of 753 patients met the inclusion criteria, comprising 663 in the surgical group and 90 in the ESD group. Among those undergoing surgery, 124 patients had T1b tumors. Of these, 25 (20.1%) had pathologically confirmed LNM, the majority of which were classified as N1 disease (14/25, 56%), indicating involvement of one to two regional lymph nodes. In contrast, 3 patients in the ESD group were found to have T1b lesions on final pathology. All three underwent additional gastrectomy and lymphadenectomy despite negative margins and no lymphovascular invasion in the initial ESD specimens. None of these patients had detectable LNM post-surgery. Overall, the ESD group showed no cases of local or distant recurrence during follow-up.

Conclusion

Our 10-year institutional data suggest that approximately one in five patients with T1b EGC harbor LNM, with most cases limited to N1 involvement. While current guidelines advocate for additional surgery in T1b EGC to address potential occult metastasis, our findings suggest that in selected patients with favorable pathological features—such as negative margins, no lymphovascular invasion, and limited submucosal depth—ESD alone may be sufficient. This underscores the need for individualized risk stratification models incorporating endoscopic, histologic, and molecular factors to avoid unnecessary surgical morbidity. Prospective studies are warranted to validate such models and optimize treatment pathways for T1b gastric cancer in the era of minimally invasive therapy.

References

1. Sun W, Liu S, Zhang H, et al. Risk factors and clinicopathological characteristics of lymph node metastasis in T1b gastric cancer: A multicenter retrospective study. Cancer Med. 2022;11(11):2234–2243. doi:10.1002/cam4.4602
2. Shichijo S, Uedo N, Kanesaka T, et al. Long-term outcomes after endoscopic submucosal dissection for differentiated-type early gastric cancer that fulfilled expanded indication criteria: a prospective cohort study. J Gastroenterol Hepatol. 2020;35(1):74–81. doi:10.1111/jgh.14780
3. Zhang L, Liu H, Xu C, et al. Lymph node metastasis and prognostic analysis in early gastric cancer: a single-center experience with 1,011 cases. J Gastric Cancer. 2024;24(1):45–53. doi:10.5230/jgc.2024.24.e5
4. Kim YI, Kim CG, Lee JY, et al. Long-term outcomes of endoscopic submucosal dissection with or without additional surgery for T1b gastric cancer. Ann Surg Oncol. 2023;30(5):1234–1242. doi:10.1245/s10434-022-12600-3
5. Fang WL, Huang KH, Chen JH, et al. The risk factors of lymph node metastasis in early gastric cancer. Pathol Oncol Res. 2015;21(4):941–946. doi:10.1007/s12253-015-9920-0
6. Choi KK, Bae JM, Kim SM, et al. The risk of lymph node metastases in 3951 surgically resected mucosal gastric cancers: implications for endoscopic resection. Gastrointest Endosc. 2016;83(5):896–901. doi:10.1016/j.gie.2015.08.052

Clinical Case Summary

A 66-year-old presented with a one-day history of abdominal pain and fevers. Computer tomography imaging (CT) revealed a foreign body in a sigmoid colon diverticulum with perforation and collection. A sigmoidoscopy failed to identify the foreign body. Ultrasound-guided foreign body extraction was unsuccessful. Surgical treatment was deemed high risk due to comorbidities and he was treated conservatively. Twelve days following a second sigmoidoscopy was performed due to persisting collection. A fish bone was found puncturing a sigmoid diverticulum. A through-the-scope (TTS) clip and methylene blue dye were applied. Removal was achieved with a snare. An over-the-scope clip (OTSC) successfully sealed the perforation.
Endoscopy is proving to be an increasingly viable minimally-invasive option for the treatment of foreign body colonic perforations when used early and in the absence of peritonitis or clinical instability¹. Unique to this case is that endoscopic closure was performed one week following perforation with associated collection, factors considered to influence procedure success due to inflammatory change^1,2. A standard TTS clip was unlikely to achieve closure strength. We used the OTSC system, designed to achieve full-thickness closure³. The technical complexity of using the OTSC system was visualisation which requires colonoscope withdrawal and mounting of a cap reducing endoscopic visibility. TTS clip and dye application prior to OTSC application proved beneficial in achieving definitive endoscopic perforation management. This is a technical aspect that to our knowledge has not been documented elsewhere in the literature.
Lessons:
1. Endoscopy can be effective in delayed colonic perforation management avoiding the need for surgery.
2. A three-step technique is proposed: 1) application of a locator (TTS clip and dye) 2) foreign body removal 3) OTSC application of the perforation site.
Fig1 CT image of fish bone and collection
Fig2 Endoscopic image OTSC

References

1) Morais R, Marques M, Macedo G. Endoscopic treatment of a foreign body–associated colonic perforation. Int. J. Colorectal Dis. 2020; 35: 165-167.
2) Rogalski P, Daniluk J, Baniukiewicz A et al. Endoscopic management of gastrointestinal perforations, leaks and fistulas. World J Gastroenterol. 2015; 21: 10542-10552.
3) Kobara H, Mori H, Nishiyama N et al. Over‐the‐scope clip system: A review of 1517 cases over 9 years. JGH. 2019; 34:22-30.

Introduction

Gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) are a heterogeneous group of tumors with rising incidence. Despite several available treatments, including somatostatin analogues (SSAs), targeted therapies (everolimus, sunitinib), and chemotherapy (capecitabine-temozolomide, CAPTEM), predicting therapeutic response and disease progression remains difficult. Tumor-related features (e.g., grading, metastatic burden) influence outcomes but whether some patient-related variables (e.g., lifestyle, comorbidities) play a role is poorly explored.

Aims & Methods

This study aimed to identify tumor and patient-related factors associated with progression and survival outcomes in GEP-NENs treated with SSAs, CAPTEM, or targeted therapies. This is a multicenter, retrospective observational cohort study including patients with well-differentiated GEP-NENs treated with SSAs, CAPTEM, or EVE/SUN. Inclusion criteria were age ≥18 years, histologically confirmed GEP-NEN, and at least 6 months of treatment. Exclusion criteria included poorly differentiated tumors, prior radioligand therapy, and MiNENs. Clinical, pathological, therapeutic, and exposome-related variables were collected. The primary endpoint was progression-free survival (PFS); overall survival (OS) was also evaluated. A target sample size of 400 was estimated for adequate power in subgroup analyses. Univariate analyses were conducted using t-tests or chi-square tests as appropriate. Associations with PFS and OS were further assessed through Cox proportional hazards models.

Results

A total of 301 patients (52.2% pancreatic) from four Italian referral centers for neuroendocrine tumors (Itanet centers) were included: 258 (85.7%) received SSAs, 32 (10.6%) CAPTEM, and 17 (5.6%) EVE/SUN. Median age at diagnosis was 59 years; 51.9% were female. Most patients (73.7%) presented with metastatic disease at diagnosis, and the majority were G2 (58%) or G3 (2.3%).
In univariate analysis, patient-related variables were not significantly associated with PFS, except for lower age at diagnosis and shorter duration of metformin use (both p = 0.05). Conversely, tumor-related variables (grading, Ki67 and presence of bone or liver metastases) were significantly associated with PFS. In multivariable Cox analysis, only liver metastases (HR 2.0), bone metastases (HR 2.15), and G3 tumors (HR 3.35) were associated with shorter PFS. For OS, univariate analysis showed worse survival in male patients (p = 0.017), those with a history of alcohol use (p = 0.027), liver disease (p = 0.013), higher tumor grading/Ki67 (p < 0.001), absence of primary tumor resection (p < 0.001), and presence of bone (p = 0.004) or liver metastases (p < 0.001). Cox multivariable analysis confirmed association of OS with male sex (HR 2.73), alcohol use (HR 6.46), G3 tumors (HR 8.26), liver metastases (HR 6.45), and absence of primary tumor resection (HR 6.45). A subgroup analysis restricted to SSA-treated patients and pancreatic NENs patients revealed similar trends.

Conclusion

In this multicenter real-world study, progression and survival outcomes in GEP-NENs were primarily driven by tumor-related variables such as grading and metastatic spread, while patient-related factors played a limited role. However, results are currently underpowered, having reached approximately 75% of the planned sample size. Future efforts will aim to expand the EVE/SUN and CAPTEM groups to enhance subgroup analyses and improve robustness of findings.

Clinical Case Summary

A 33-year-old female patient was referred to the emergency after a polytrauma. CT scan showed a fracture of the pelvis as well as rupture of the anteroinferior wall of the urinary bladder. Conservative treatment of the bladder injury with indwelling urinary catheter was indicated and an orthopedic surgery was performed. During the immediate postoperative period, the patient had urine leaking through the suprapubic surgical wound. A second surgery was indicated by the Urology team, who sutured bladder injury. After 3 days, high volume of urine leaked through the surgical wound (2,5 L per day). A bilateral ureteral catheter was inserted to divert urinary flow but without improvement. The endoscopy team was asked to assess the possibility of vacuum therapy. Flexible cystoscopy jointly conducted by the urology and endoscopy teams identified a fistula in the right anterior wall of the bladder that communicated with surgical wound dehiscence. A Teflon guide wire was passed through the fistula and exteriorized through the skin orifice. A size 12 urethral tube was passed through the guide wire and the urethra, with the distal end externalized through the skin wound. The tube was adapted with fenestrated film (modified vacuum therapy) and a thread (2-0 Ethibond) was left at the distal end to serve as a guide for future changes. Under direct vision, the catheter was pulled and placed in the fistulous tract. An occlusive dressing was applied to the surgical wound and a functioning vacuum was achieved. The indwelling urinary catheter and antibiotic therapy were continued during treatment. A reduction in urine output through the surgical wound was observed. The catheter was changed once a week guided by cystoscopy using the thread left during the first procedure. Two changes were made, with a total treatment duration of 21 days. The urine output from the surgical wound had ceased completely. The control tomography showed complete closure, with no contrast extravasation.

Introduction

Colonic polypectomy is a widely used endoscopic technique for colorectal cancer prevention. However, post-polypectomy bleeding (PPB) and local recurrence remain notable complications. Snare Tip Coagulation (STC) involves the application of thermal coagulation to the resection margin using the tip of the snare after polyp removal. This study aimed to evaluate the clinical efficacy of STC in reducing immediate and delayed PPB, as well as local recurrence, following polypectomy.

Aims & Methods

We retrospectively reviewed 156 patients who underwent endoscopic resection—either snare polypectomy or endoscopic mucosal resection (EMR)—for pedunculated or sessile colorectal polyps measuring 6–20 mm at a single center between January 2022 and February 2024. Patients were divided into two groups: those who received STC (n=78) and those who did not (control group, n=78). Primary outcomes included the incidence of PPB within 14 days and local recurrence at 12-month follow-up colonoscopy.

Results

The STC group demonstrated significantly lower rates of early (0.4%) and delayed (1.6%) PPB compared to the control group (1.9% and 3.8%, respectively; p<0.05). Local recurrence was also significantly reduced in the STC group (1.3%) versus the control group (4.8%; p=0.01). No significant differences were observed between the groups regarding procedure time or major complications such as perforation.

Conclusion

Snare Tip Coagulation is a safe and effective adjunctive technique in colorectal polypectomy, significantly reducing the risk of both post-procedural bleeding and local recurrence without increasing procedural complications. STC may offer particular benefit in the resection of medium-sized colorectal adenomas and should be considered for integration into routine endoscopic practice.

References

1. ​Snare Tip Soft Coagulation vs Argon Plasma Coagulation vs No Margin Treatment After Large Nonpedunculated Colorectal Polyp Resection: a Randomized Trial. Douglas K Rex, Gregory B Haber, Mouen Khashab, et al. Clin Gastroenterol Hepatol. 2024 Mar;22(3):552-561.e4.
2. Recurrences of advanced sessile and lateral spreading colorectal adenoma after endoscopic mucosal resection (EMR) thermal ablation versus no adjuvant therapy (RESPECT): a protocol of an international randomized controlled trial. Kemper G, Gerges C, Schoon EJ, Schreuder RM, Schrauwen RRW, Epping LSM, Beyna T, Drenth JPH, Gündug U, Siersema PD, van Geenen EJM; ENDOCARE study group.Trials. 2024 Feb 17;25(1):132. doi: 10.1186/s13063-024-07915-2.

Disclosure

Nothing to disclose

Introduction

Hepatocellular carcinoma (HCC), the sixth most prevalent malignancy and third leading cause of cancer-related mortality globally, accounts for 75-85% of primary liver cancers with a 5-year survival rate below 20%. Early-stage HCC is managed by resection or ablation, while advanced cases rely on transarterial therapies and systemic treatments. However, drug resistance to multi-kinase inhibitors (e.g., sorafenib) significantly limits efficacy. HCC progression is closely linked to an immunosuppressive tumor microenvironment characterized by T-cell co-stimulatory molecule deficiency and checkpoint activation (PD-L1/CTLA-4), driving T-cell exhaustion. Recent evidence highlights intratumoral microbiota dysbiosis as a modulator of immune remodeling, yet the spatial distribution patterns and regulatory mechanisms of bacterial communities within HCC lesions remain poorly defined.

Aims & Methods

This study employed invasion-adhesion-directed expression sequencing (INVADE-seq) integrated with single-cell host transcriptomics to profile intratumoral microbiota and construct microbial-immune interaction networks in five HCC tumors and paired adjacent normal tissues. Peritumoral microbiome analysis was conducted using 2b-Rad-M sequencing. Through systematic bacterial isolation (LB/Columbia/BCSA/Schaedler media) and Sanger sequencing validation, Pseudomonas koreensis (P.K) was identified as a key HCC-associated strain. Spatial localization and ultrastructural characterization were achieved via fluorescence in situ hybridization (FISH), multiplex fluorescence staining, and electron microscopy. Whole-genome sequencing delineated its genomic architecture, while metabolomics uncovered unique metabolic signatures. Functional validation using orthotopic HCC models (MYC/Alb and NSG mice) revealed its pro-tumorigenic role and immunomodulatory effects.

Results

2b-Rad-M sequencing showed significantly higher abundance of Bacillus, Pseudomonas, and Klebsiella in HCC tissues compared to adjacent non-tumor tissues, with reduced bacterial diversity. Circos plots highlighted increased Proteobacteria and Firmicutes in HCC. Through culturing and Sanger sequencing, P.K was identified as a dominant strain in HCC, showing quinolone sensitivity and urease activity. FISH confirmed its widespread presence in HCC tissues, with elevated abundance in T cells from advanced-stage patients. INVADE-seq analysis of five additional HCC tissue pairs also detected P.K Single-cell INVADE-seq revealed that T cells harboring this bacterium exhibited increased exhaustion scores and upregulated TOX expression. In MYC/Alb mice, oral gavage of P.K accelerated hepatocarcinogenesis, but no significant effect was observed in NSG immunodeficient mice, indicating immune system dependency. Whole-genome sequencing linked HCC-derived P.K to the fish pathogen P. koreensis CM-01, with enriched amino acid and carbon metabolism pathways. Metabolomics analysis associated it with purine/pyrimidine metabolism and cGMP-PKG signaling. Reduced spermidine levels impaired fatty acid oxidation, exacerbated T cell exhaustion, and promoted an immunosuppressive microenvironment, enhancing tumor proliferation, invasion, and metastasis.

Conclusion

This study reveals how intratumoral microbiota regulate the tumor microenvironment via the metabolism-immune axis, offering new insights into HCC immunotherapy. Targeting P.K-related metabolic pathways may provide a novel therapeutic strategy.

Disclosure

The authors declare no conflict of interest.

Introduction

Pancreatic necrosis is a devastating disease that leads to a high mortality and morbidity rates. Necrosectomy is the golf standart treatment for infected pancreatic necrosis. Percutaneous and endoscopic approaches has been widely accepted in selected cases. Endoscopic necrosectomy in early complicated pancreatic necrosis were performed as a first intent to treat and retrospectively evaluated regarding to morbidity, efficacy, recurrence and length of hospital stay.

Aims & Methods

Report our experience on endoscopic manage of pancreatic necrosis using a daily transmural and transpapillary drainage in 25 patients.
Records of all patients who underwent EN from January 2023 to January 2025 Endoscopic manage of acute pancreatic necrosis using a daily transmural and transpapillary drainage in 25 patients. The Apache classification and CCT score is used. Diagnostic ERP to search communications between pancreatic duct and the collection were performed in selective cases and in cases that communication exists; prothesis can be inserted through the minor or major papilla to plug it. The transmural drainage was performed in 25 patients (05 Duodenal and 20 gastric) and transpapillary and transmural in 07 patients, after identification of the most proeminent or bulging part of the stomach or duodenum. All patients were followed with CT scans, IRM to ensure clinical resolution.

Results

25 patients (14 women, 09 men) could be treated. The Apache classification is used 0 a 9 score in 14 patients (56,%) and 11 (44%), CT severity index was 30-50% in 05, > 50% in 20. Pancreatic necrosis were located in the pancreatic head in 03 patients, the head/body in 02, body in 6, body/tail 04, head/body/tail 10. ERP demonstrated the ductal communication of the colection with the main pancreatic duct in 07 patients, rupture in 03, disconnect syndrome in 03 and normal in 02. Drainage was successful in 25 (100%). 07 (28%) combined treatment (transpapillary and transmural), 18 (72%) transmural. The median number of endoscopic session for each patients was 4 (range 2 to 8). The median hospital stay for in the all patients was only endoscopic therapy was 9. The range follow –up was 18 months (range 6 to 24) with mean number of ERCPs was 4 (range 2 to 8). Two patients required concurrent radiology procedure, recurrence of fluid collection (n=1), flank abscess (n=1). There were 2 (16,6%) pseudocyst recurrences during this period, and were managed clinically and/or endoscopically. There was no mortality related to the procedure.

Conclusion

The early and aggressive endoscopic treatment with daily necrosectomy can be performed and show promising results same in early complications of pancreatic necrosis. Combined approaches with radiology and conventional surgery can also be applied in selected cases.

Disclosure

No Conflict of Interest