Introduction

​Endoscopic ultrasound guided gallbladder drainage (EUS-GBD) with lumen apposing metal stent (LAMS) has become a favourite drainage option for high surgical-risk patients with acute cholecystitis and as rescue treatment for the relief of jaundice in patients with distal malignant biliary obstruction (DMBO) with high technical and clinical success.
Both trans-gastric and trans-duodenal drainage are described but which is the best way is still controversial.

Aims & Methods

We aim to compare the two different approaches in term of technical success, rate of adverse events, unplanned readmissions and re-interventions.
Single center retrospective analysis of all consecutive cases of EUS-GBD with LAMS acceding to the Therapeutic Endoscopy Unit of Fondazione Policlinico Universitario Campus Bio-Medico of Rome. Data about LAMS features and procedure were collected.

Results

From January 2019 to September 2024 sixty patients were enrolled (50% male; 77±12 years old). The 60% of them underwent EUS-GBD for acute cholecistitis. In 31/60 (52%) patients the trans-gastric access was performed. In 43/60 (71.7%) patients a Hot-Axios LAMS was used and in the majority of procedure (47/60 78.3%) a calibre bigger than 10 mm was used. Overall technical success was obtain in 98.3% of procedures.
In no case the LAMS was dilated. A naso-cistic tube was placed inside the LAMS in 31/60 patients. Double pig-tail plastic stent was placed in two patients. Regarding the adverse events rate, in one patient distal flange misdeployment occurred. LAMS obstruction occurred in 7/60 patients (11.7%) and need of reintervention in 10/60 (16.7%).
There was no difference in term of drainage indication, technical success rate, type and size of LAMS used, naso-cystic tube or pig-tail stent insertion between the two different EUS-GBD access. However, the trans-gastric access was associated with a higher rate of LAMS obstruction (6/7 vs 1/7 p 0.05) and need of re-intervention (8/10 vs 2/10 p 0.03).

Conclusion

EUS-GBD is a safe technique with high technical success rate. Both trans-gastric and trans-duodenal approaches are effective. However, EUS-GBD with trans-gastric access seems to be associated with a higher rate of late adverse events and when possible another way should be preferred.

Introduction

Defecatory dysfunction (DD) is a common cause of chronic constipation resulting from functional abnormalities or structural pelvic pathologies. Accurate diagnosis requires combining anorectal manometry (ARM), balloon expulsion test (BET), and defecography. This study evaluates the diagnostic utility of these modalities and explores uncertainties in their performance and interpretation.

Aims & Methods

This retrospective study included 325 adult patients assessed for DD between 2020 and 2023. All patients went through ARM, BET in the left lateral position, and defecography. Statistical associations between test outcomes were analyzed to assess diagnostic concordance and significance.

Results

A strong correlation was observed between ARM and defecography, with 65% of patients with normal anal relaxation on ARM achieving normal rectal evacuation on defecography (p < 0.0001). Conversely, patients with paradoxical contraction during ARM demonstrated a higher likelihood of evacuation failure. BET demonstrated high specificity but limited sensitivity in association with relaxation on ARM and evacuation on defecography. BET failure did not demonstrate a significant association with the presence of pelvic floor pathologies.

Conclusion

Combining ARM, BET, and defecography provides a comprehensive framework for diagnosing DD, addressing its functional and structural components. This integrated approach facilitates targeted interventions, ultimately improving clinical outcomes.

References

Chronic constipation is a common disorder with multifactorial pathophysiology, including pelvic floor dysfunction (Bharucha & Lacy, 2020). Symptomatic pelvic floor disorders affect a significant proportion of women (Nygaard et al., 2008). High-resolution anorectal manometry (HRAM) and rectal balloon expulsion tests are critical for diagnosing defecatory disorders (Prichard et al., 2017; Bharucha & Coss-Adame, 2022). Standardized protocols, including the London Classification, have improved the diagnostic accuracy of anorectal functional tests (Carrington et al., 2020; Carrington et al., 2018). Imaging modalities such as magnetic resonance defecography complement functional testing (Reiner et al., 2011; Carter et al., 2020). Variations in body position influence anorectal test results (Su et al., 2019; Wu et al., 2017; Tsunoda et al., 2022; Ratuapli et al., 2013). Comparative studies emphasize the complementary role of manometry, balloon expulsion, and defecography (Blackett et al., 2022; Heinrich et al., 2015). Recent advances suggest HRAM improves detection of specific defecatory mechanisms (Deb et al., 2022; Sharma et al., 2020), supported by international consensus guidelines (Wald et al., 2021; Rao & Tetangco, 2020; Lee & Bharucha, 2016).

Disclosure

no conflict of interest

Introduction

Self-expandable metallic stent (SEMS) placement is a palliative treatment for inoperable esophageal malignancies to improve the quality of life. Traditional methods rely on fluoroscopy and endoscopy, but anatomical landmarks can simplify the procedure.

Aims & Methods

To evaluate the technical success, safety and reproducibility of using vertebral column and diaphragm landmarks for SEMS placement.
This retrospective observational study included 801 patients with inoperable esophageal malignancies undergoing SEMS placement for dysphagia due to malignant esophageal strictures, by using vertebral column and diaphragm as landmarks, from 1^st January 2006 to 31^st December 2024. The primary endpoint was to assess the technical success, safety and reproducibility of this unique technique for SEMS placement.
Methodology for Stent Placement in Esophageal Tumors:
1. For Proximal or Mid-Esophageal Tumor, following algorithm was followed: Step 1: Identify key anatomical landmarks using fluoroscopy. Step 2: With the scope in place, under fluoroscopic guidance, identify the vertebra in line with the distal extent of the tumor using the diaphragm as a reference, followed by identification of vertebra at the proximal extent of the tumor. Count the vertebrae between the distal and proximal extent of the tumor. Assign a length of 2.5 cm per vertebral body. Ascertain the desired size of SEMS by calculating the total length of the stricture by counting the vertebrae, adding one vertebral body above and below the tumor for proper stent placement. Step 3: Using fluoroscopy, position the stent. Place the distal end of the stent at the distal vertebral marker. Position the proximal end of the stent at the proximal vertebral marker. Release the stent at the appropriate position to ensure full coverage of the stricture.
2. For Tumor Extending Beyond the Gastro-Esophageal Junction (GEJ), following algorithm was followed: Step 1: Identify the proximal extent of the tumor. Align the proximal extent of the tumor with the vertebra, using the diaphragm as a reference for precise alignment. Measure the distance from the proximal end of the tumor to the proximal stomach using the scope to decide the required size of the stent. Step 2: Place the stent under fluoroscopic guidance. Position the upper end of the stent at the identified vertebra. Extend the distal end of the stent into the stomach, past the GE junction to ensure proper coverage. Release the stent.

Results

408 (50.9%) patients were females. The age range was 18-95 years (mean50±Standard deviation15). Predominant presenting complaint was dysphagia (85.39%). Average duration of dysphagia was 3.84 months. 594 (74.16%) patients had squamous cell carcinoma, whereas 207 (25.84%) patients were diagnosed with adenocarcinoma on histopathology. 365 (45.57%) patients had tumor confined to the lower one-third of esophagus. Major cause of inoperability was distant metastasis (52.81%). 240 (30%) patients had involvement of GEJ. Average length of malignant stricture was 8.4 cm. 139 (17.40%) patients required dilatation by using savary gilliard dilators before SEMS placement. TEF was present in 48 (6%) patients. Range of length of SEMS was 8-18 cm (12.5±2.26). Technical success was achieved in 100% cases. No major immediate complications occurred. Minor complications were rare.

Conclusion

Using vertebral column and diaphragm landmarks is a reliable, safe, simplified and reproducible approach for SEMS placement in patients with inoperable esopahgeal malignancies.

References

1. Lander S, Lander E, Gibson MK. Esophageal Cancer: Overview, Risk Factors, and Reasons for the Rise. Curr Gastroenterol Rep. 2023 Nov;25(11):275-279. doi: 10.1007/s11894-023-00899-0. Epub 2023 Oct 9. PMID: 37812328.

2. Li J, Xu J, Zheng Y, Gao Y, He S, Li H, Zou K, Li N, Tian J, Chen W, He J. Esophageal cancer: Epidemiology, risk factors and screening. Chin J Cancer Res. 2021 Oct 31;33(5):535-547. doi: 10.21147/j.issn.1000-9604.2021.05.01. PMID: 34815628; PMCID: PMC8580797.

3. Asghar MS, Khan NA, Kazmi SJH, Hassan M, Rasheed U, Jawed R, Yaseen R, Naqvi SAA. Clinical, epidemiological, and diagnostic characteristics of esophageal carcinoma in a Pakistani population. Ann Saudi Med. 2021 Mar-Apr;41(2):91-100. doi: 10.5144/0256-4947.2021.91. Epub 2021 Apr 1. PMID: 33818145; PMCID: PMC8020643.

Introduction

The impact of antral preservation versus antral resection in sleeve gastrectomy remains a subject of debate due to its potential effects on weight loss, metabolic outcomes, and gastrointestinal function. This meta-analysis aims to provide a comparative assessment of these surgical techniques.

Aims & Methods

The Meta-Analysis aims to provide a comprehensive analysis between ​these two surgical techniques.
A systematic review and meta-analysis were conducted using 10 studies published between 2014 and 2025 that compared sleeve gastrectomy with antral preservation versus antral resection. The primary outcomes included excess weight loss (EWL) at different time points, while secondary outcomes assessed metabolic parameters (C-peptide, GLP-1, HbA1c), gastric emptying, gastroesophageal reflux disease (GERD), and resolution of comorbidities.

Results

A total of 10 studies were included. Patients undergoing antral resection exhibited greater excess weight loss at 6 and 12 months (MD: -4.50, 95% CI: -5.98 to -3.02; MD: -6.11, 95% CI: -7.74 to -4.47, respectively; p<0.00001), though the difference diminished by 24 months (MD: -3.37, 95% CI: -7.04 to 0.30; p=0.07). No significant differences were observed in overall GERD incidence (RR: 1.00, 95% CI: 0.75–1.33) or complications (RR: 1.00, 95% CI: 0.74–1.42). Metabolic outcomes showed marginal differences, with C-peptide (SMD: 0.02, 95% CI: -0.38 to 0.42) and GLP-1 (SMD: -0.22, 95% CI: -0.90 to 0.47) exhibiting minimal changes between groups.

Conclusion

Antral resection in sleeve gastrectomy is associated with superior short-term weight loss, but long-term differences remain inconclusive. Metabolic outcomes and postoperative complications appear comparable between techniques. Further randomized controlled trials with extended follow-up are warranted to refine surgical recommendations.

References

Disclosure

The author(s) declare no conflict of interest

Clinical Case Summary

Gastric neuroendocrine tumors (NETs) are classified into three types based on their pathogenesis. Type 3 NETs are sporadic, not hypergastrinemia associated , and typically present as solitary, aggressive lesions with a higher metastatic potential. Current ENETS guidelines recommend surgical resection for lesions larger than 20 mm, particularly for Type 3 NETs, to minimize the risk of metastasis. We present the case of a 54-year-old male admitted for syncopal episodes and anemia (Hb 10.5 g/dL). After treatment with acetylsalicylic acid and enoxaparin for suspected myocardial ischemia, he developed a pre-syncopal event and a drop in hemoglobin to 6.8 g/dL. Urgent esophagogastroduodenoscopy (EGDS) revealed a 20 mm pedunculated polyp in the gastric body (Fig 1-2-3). Biopsies confirmed a neuroendocrine tumor (NET) with a Ki67 index of 1%. Systematic gastric mucosal mapping showed no other histological abnormalities, supporting the diagnosis of a sporadic Type 3 NET. Staging with contrast-enhanced CT, 68Gallium PET (68Ga-DOTATOC), and endoscopic ultrasound (EUS) excluded local invasion, nodal involvement, and distant metastases. Given the 0-Ip morphology according to the Paris classification, an endoscopic resection was performed using a hot snare technique with endoloop placement at the base of the peduncle. Histology confirmed a 21 mm NET G2 (Ki67 8%) with submucosal infiltration but no vascular or lymphatic invasion (Fig 4-5). Resection margins were clear. At six months, EGDS and 68Ga-PET showed no evidence of recurrence or residual disease. This case underlines how, even in Type 3 NETs larger than 20 mm, the pedunculated morphology can allow for complete and safe endoscopic resection, similarly to what is observed in the management of colonic polyps. Further studies are needed to better define the role of morphology in therapeutic strategies for gastric NETs. This is the only reported case of a pedunculated Type 3 NET of this size successfully treated endoscopically.

References

Figure 1. Upper gastrointestinal endoscopy revealed a 20 mm pedunculated polyp in the gastric body, corresponding to a Paris 0-Ip lesion. The surface appeared smooth, with signs of erosion and ulceration.

Figure 2. Linked Color Imaging (LCI) enhanced the vascular and mucosal pattern, showing a well-circumscribed lesion with preserved pit pattern, suggestive of a subepithelial neoplasm suitable for endoscopic resection.

Figure 3. Endoscopic view of the resection using a hot snare technique and prophylactic endoloop placement at the stalk base. Complete resection was achieved without complications.

Figure 4. Hematoxylin and eosin staining, 10x. The tumor arises from histologically normal oxyntic mucosa, without adjacent endocrine hyperplasia, consistent with a sporadic Type 3 gastric neuroendocrine tumor.

Figure 5. Immunohistochemistry panel of the resected specimen. The tumor shows diffuse positivity for Chromogranin A, Synaptophysin, and Somatostatin Receptor 2 (SSTR2). The Ki67 (MIB-1) proliferation index was 8%, consistent with a Grade 2 NET. No lymphovascular invasion was identified, and resection margins were clear.

Clinical Case Summary

An 81 year-old male, with no relevant medical history, presented to the emergency department with hematemesis, hemodynamic instability and hemoglobin of 4.5 g/dL. Upper gastrointestinal endoscopy (UGE) revealed 30 mm excavated gastric ulcer at the incisura angularis, with a visible vessel (Forrest IIa). Initial attempt using over-the-scope clip (OTSC) failed due to inability to pass the upper esophageal sphincter despite multiple expert attempts. Subsequent therapy with epinephrine and two through-the-scope (TTS) clips achieved initial hemostasis. However, patient experienced three rebleeding episodes in the following days, requiring repeated endoscopic interventions, including thermocoagulation with Bipolar Circum-Active Probe (BICAP). Biopsies of the ulcer margins were negative for dysplasia/malignancy.
During the third episode, combined therapy with epinephrine and 1% polidocanol (4 cc) was administered into the vessel. The following day, due to hematemesis, he repeated UGE that revealed extensive, friable, violet-colored ulceration of the gastric body and antrum, consistent with ischemic injury likely secondary to polidocanol injection. Patient was managed conservatively with proton pump inhibitors and antibiotics for one week.
After eight months of follow-up, he remains clinically stable, without episodes of rebleeding. A reassessment endoscopy showed only a scar retraction.
This case is presented based on the iconography of the adverse effect of polidocanol therapy (exuberant gastric ischemia), highlighting the risk of gastrointestinal necrosis. However, as this is a refractory ulcer with multiple episodes of rebleeding, polidocanol proved to be the most effective therapy. Literature describes similar risks with adrenaline and sclerosant agents. In this case, we suggest that direct arterial injury by the needle, followed by immediate luminal obliteration, led to ischemic damage.

References

Li WF, Gao RY, Xu JW, Yu XQ. Endoscopic treatment of bleeding gastric ulcer causing gastric wall necrosis: A case report. World J Gastrointest Surg 2024; 16(4): 1203-1207
Silva C, Monteiro C, Matos C, Martins A, Midões A. Extensive duodenal ischemia after endoscopic hemostatic therapy. Int J Case Rep Images 2022;13(2):202–204.
J. Molina-Infante, M. Fernandez-Bermejo, G. Vinagre-Rodríguez. Severe gastric ischemia after combined sclerotherapy for bleeding gastric ulcer. Endoscopy 2011; 43: E191.
G. Dorta, P. Michetti, P. Burckhardt, M. Gillet. Acute ischemia followed by hemorrhagic gastric necrosis after injection sclerotherapy for ulcer. Endoscopy 1996; 28.

Clinical Case Summary

Background: Enteric duplication cysts are one of the rarest lesions detected in the pancreas. Pancreatic duplication cysts can be challenging to distinguish from neoplastic lesions, particularly in symptomatic patients. Radiologic imaging, such as Computed Topography (CT) and Magnetic Resonance Imaging (MRI), may not always provide a clear differentiation, leading to potential misdiagnosis.
Case presentation: We present the case of a Fifty-seven male patient with a history of long-standing epigastric pain, dyspepsia, and weight loss. Upper and lower endoscopy showed only mild gastritis. Abdominal CECT abdomen showed a well-circumscribed pancreatic lesion of about 20x25 mm with no vascular invasions. Endoscopic ultrasound showed a well-circumscribed pancreatic neck lesion about 20x22 mm, anechoic, negative color flow doppler, soft on elastography, free surrounded vessels with no posterior acoustic enhancement. EUS suggested a cystic lesion versus a vascular NET. EUS fine-needle aspiration (FNA) was done with aspiration of gelatinous material and onsite cytopathology suggested a benign cystic lesion. Further pathological interpretation confirms the diagnosis of a duplication cyst leading to appropriate management without avoidance of major invasive surgical intervention.
Conclusion: EUS and EUS-guided biopsy have a crucial role in differentiating benign pancreatic conditions from malignancies, particularly in patients presenting with nonspecific symptoms and ambiguous radiologic findings. EUS should be considered early in the diagnostic process to avoid misdiagnosis and unnecessary surgical procedures.

Disclosure

Nothing to disclose