Introduction

Short-septum Zenker’s diverticulum (ZD) is considered difficult-to-treat because the limited anatomical space which restricts the operating area. Recently, peroral endoscopic septotomy (POES) emerged as a novel third-space technique for addressing this condition.

Aims & Methods

This study aims to compare the effectiveness and safety of POES with traditional flexible endoscopic septotomy (FES) for the treatment of symptomatic patients with short-septum ZD (<25 mm). In this single-center, prospective study we included all consecutive patients referred to Humanitas Research Hospital with symptomatic short-septum ZD who were scheduled to undergo either FES or POES. The primary outcome was the rate of technical success and adverse events (AEs). The secondary outcome was the rate of clinical success at 12 months and recurrence requiring a retreatment. A sensitivity analysis was conducted using propensity score matching. Hazard Ratio (HR) and its associated 95%CI were used for a time-dependent analysis of recurrence.

Results

A total of 94 patients (63.8% male; mean age 72.7 + 10.7 years) underwent endoscopic treatment for a short-septum ZD (mean size 17.0 + 4.3 mm) were included. Among them, 41.5% (n=39) were treated with FES and 58.5% (n=55) with POES (p=n.s.). Overall, the mean procedural duration was 25.3 + 15.7 min, while the mean hospital stay was 0.3 days. Septotomies were performed under deep sedation in 91.5% of patients (n=86), while in 8.5% of them (n=8) the procedure was performed under general anesthesia. Technical success was achieved in 98.9% of patients (n=93), while AEs occurring in 5.3% of cases (n=5), with no statistical difference between groups (p=n.s.). Clinical success was observed in 91.5% of patients (n=86), while recurrence necessitating retreatment in 14.9% of cases (n=14) with no statistical difference between groups (p=n.s.).

Conclusion

Our findings suggest that POES is an effective and safe technique for the treatment of short-septum ZD, showing comparable outcomes to traditional FES.

References

Repici A, Spadaccini M, Belletrutti PJ, et al. Peroral endoscopic septotomy for short-septum Zenker's diverticulum. Endoscopy. 2020 Jul;52(7):563-568.

Introduction

Colonic diverticulosis is a prevalent gastrointestinal condition that is often diagnosed incidentally. However, its association with chronic polyps and rectal hemorrhoids remains underexplored, particularly in the northern region of Saudi Arabia.

Aims & Methods

This study aimed to assess the relationship between colonic diverticulosis and colonic conditions while considering demographic and clinical factors. This retrospective observational study was conducted at a tertiary referral center over four years. Data from 4,014 patients who underwent colonoscopy were analyzed. Statistical tests, including chi-square and independent sample t-tests, were used to determine associations between diverticulosis, polyps, hemorrhoids, and bowel preparation adequacy.

Results

Diverticulosis was observed in 14.2% of the patients, with a higher prevalence among males (16.1%) than among females (12.1%) (p < 0.001). Patients with diverticulosis were significantly older (mean age 61.35 years) than those without diverticulosis (mean age 48.25 years) (p < 0.001). Hemorrhoids were more frequent in patients with diverticulosis (18.6%) than in those without diverticulosis (11.9%) (p < 0.001). A similar association was found between diverticulosis and polyps, with the polyp prevalence being higher in patients with diverticulosis (21.4%) than in those without (11.7%) (p < 0.001). Additionally, inadequate bowel preparation was more common among patients with diverticulosis (17.1%) than among those with adequate bowel preparation (13.6%) (p = 0.023).

Conclusion

This study highlights a significant association between colonic diverticulosis and the presence of polyps and hemorrhoids. Older age and male sex were identified as the key risk factors. These findings emphasize the importance of targeted screening and optimized bowel preparation in at-risk patients. Further research is required to explore the underlying pathophysiological mechanisms and to develop preventive strategies.
Keywords: Diverticulosis; Hemorrhoids; Chronic Polyps

References

1 Nallapeta NS, Farooq U, Patel K. Diverticulosis. StatPearls. Treasure Island (FL): StatPearls Publishing 2025.
2 Tursi A, Scarpignato C, Strate LL, et al. Colonic diverticular disease. Nat Rev Dis Primers. 2020;6:20. doi: 10.1038/s41572-020-0153-5

Clinical Case Summary

We present a rare case of protein losing gastropathy.A 60-year-old female presented to our clinic with 10 years history of intermittent dyspepsia with no alarm features and peripheral oedema for 6 months.Physical examination was unremarkable except mild bilateral pitting oedema.Pertinent investigations suggested normal albumin,urine analysis,renal&liver profiles and a normal echocardiogram.Subsequent testing with esophagogastroduodenoscopy(EGD) for dyspepsia showed hypertrophied mucosal folds predominantly in gastric corpus while sparing the antrum.Full thickness biopsies were taken and sent for histopathology with differentials of Lymphoma,adenocarcinoma,sarcoidosis and Menetrier’s disease.Stool antigen for Helicobacter Pylori(H.Pylori)thereafter,was positive while Contrast enhanced CT abdomen was consistent with mildly thickened gastric walls.Histological examination demostrated foveolar hyperplasia,elongated gastric pits and cystically dilated gastric glands without any features of malignancy.Hence a diagnosis of Menetrier’s disease(underlying H.Pylori) was made.
Patient then had H.Pylori eradication therapy as well as a diet rich in medium-chain fatty acids and proteins.H.Pylori eradication was confirmed.6 months follow up revealed partial resolution of her symptoms but no change in endoscopic findings.Patient could not undergo further treatment with biologics(cetuximab)due to financial constraints and octreotide for its local unavailability.She is now on a yearly endoscopic surveillance for future high risk of gastric malignancies.

References

​​Fig1A.Haematoxylin & Eosin staining shows foveolar & mucous cell hyperplasia,elongated gastric pits and lymphocytic infiltration.
Fig1B.Haematoxylin & ​Eosin staining shows cystic dilation of gastric glands
1.Pepa P, Uehara T, Wonaga A, Redondo A, Avagnina A, Mazzocchi O, Antelo P, Waldbaum C, Sorda J. Menetrier's disease. A diagnostic and therapeutic challenge. Medicina (B Aires). 2021;81(3):470-473. English. PMID: 34137712.
2.Gore M, Bansal K, Jadhav N. Menetrier Disease. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan– [updated 2023 Jun 25].

Disclosure

No conflicts

Introduction

Branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) are frequently associated with acute (AP) or recurrent pancreatitis (RP), likely due to the mucin-induced obstruction of the main pancreatic duct (MPD). According to the 2024 Kyoto Guidelines, pancreatitis represents an indication for surgical evaluation in IPMN patients. However, pancreatic sphincterotomy (PS) may represent a less invasive alternative for patients who are unfit for surgery or as a bridge to surgery, aiming to reduce the risk of further pancreatitis episodes.

Aims & Methods

This single-center retrospective study aimed to assess the efficacy and safety of PS in patients with BD-IPMN and RP. We included 33 patients who underwent PS between 2016 and 2023, with at least 12 months of follow-up. Patients with other causes of RP or prior pancreatic surgery were excluded. The frequency of pancreatitis episodes before and after PS was compared. Clinical success was defined as complete resolution or ≥50% reduction in pancreatitis episodes. Adverse events, presence of worrisome features (WF), and progression to high-risk stigmata (HRS) were evaluated. Statistical analysis was performed using paired t-test and Fisher’s exact test, with p < 0.05 considered significant.

Results

Among the 33 patients analyzed (39.4% female, 60.6% male, mean age 59 ± 13.9 years) clinical success was achieved in 81.8% of the cases. Specifically, 72.7% of the patients experienced no further AP episodes after PS and 9.1% experienced a reduction in episode frequency, while 18.2% of patients did not respond to treatment. Adverse events occurred in 15% of patients, including: 12% with post-ERCP pancreatitis (all mild) and 3% with intra-procedural bleeding; no perforations were reported. During follow-up WF emerged in 5 patients (15%), while no cases of HRS were identified. Among the 6 non-responders, 3 underwent a second PS, with 2 achieving clinical improvement, and 3 underwent duodenocephalopancreasectomy (DCP), including 1 for a concomitant pancreatic ductal adenocarcinoma (PDAC) unrelated to IPMN progression. Notably, no cases of IPMN degeneration were observed in the series

Conclusion

Pancreatic sphincterotomy appears to be a safe and effective approach for managing recurrent pancreatitis in patients with BD-IPMN, potentially reducing the need for surgery in selected cases.

Introduction

Microscopic colitis (MC) is an inflammatory condition of the large intestine. Primarily diagnosed in middle-aged and older adults, the age-specific incidence of the disease peaks in patients 75-79 years of age. While MC is associated with a reduced quality of life, large-scale studies on the association with future psychiatric disorders are lacking.

Aims & Methods

Due to the burden of symptoms as well as inflammatory similarities between MC and certain psychiatric disorders, we hypothesized that patients with MC were at an increased risk of psychiatric disease. Using the nationwide histopathology cohort ESPRESSO, we identified 5,816 patients in Sweden with MC. These patients were matched, according to birth year, sex, and county, with reference individuals (n=21,509) from the general population. All individuals with previously recorded psychiatric disorders or dispensation of medication indicative of psychiatric morbidity were excluded. Our main outcome measure was a pre-devised collection of ICD-codes, all indicating psychiatric disease. Moreover, to control for the impact of intrafamilial confounding, full siblings to patients with MC were identified, and in a sensitivity analysis, used as reference population. Adjusted hazard ratios were computed using Cox proportional hazards modelling. Our main analysis included adjustments for the matching factors (birth year, county, sex) as well as educational attainment (as a proxy for socioeconomic status) and inflammatory bowel disease, celiac disease, and type 1 diabetes.

Results

From 2006-2021, 519 patients with MC and 1,313 reference individuals were diagnosed with psychiatric disorders (9.9 vs. 6.5 events per 1,000 person-years), corresponding to one extra case of psychiatric disorder in 29 patients with MC over 10 years. After adjustments, this represented a hazard ratio (HR) of 1.57 (95% confidence interval [CI]=1.42-1.74). We found significantly elevated estimates up to 10 years after MC diagnosis and similar HRs in lymphocytic and collagenous colitis. More specifically, we observed increased risks for unipolar depression, anxiety disorders, stress-related disorders, substance abuse, and suicide attempts in patients with MC.
Our result was robust across several sensitivity analyses
(Table 1).

Conclusion

Patients with MC are at increased risk of incident psychiatric disorders compared to the general population. Specifically, this increased risk applies to unipolar depression, anxiety disorders, stress-related disorders, substance abuse, and suicide attempts. The increased risk was most pronounced among older patients with MC.

References

NA

Disclosure

Dr Ludvigsson has coordinated a study for the Swedish IBD quality register (SWIBREG). That study received funding from the Janssen Corporation. Dr Ludvigsson has also received financial support from MSD to develop a paper reviewing national healthcare registers in China. Dr Ebrahimi has served as an advisory board member for Boehringer Ingelheim. Dr Pardi has consulted for Immunic Therapeutics, Takeda, AbbVie, Boehringer Ingelheim, and Lilly.

Introduction

Esophageal squamous cell carcinoma (ESCC) often develops the synchronous or metachronous multiple ESCC. Although the Japanese guideline recommended endoscopic examination as surveillance at least once a year after endoscopic resection (ER) of ESCC, the optimal surveillance modality was not specified. In clinical practice, image-enhanced endoscopy (IEE) followed by Lugol chromoendoscopy (LCE) is commonly performed. While LCE reduces the proportion of missed lesion, it has low specificity and causes severe discomfort to the patients, so attempts have been made to omit Lugol's staining. It is unknown what lesions may be missed at this time point by omitting LCE in surveillance after esophageal ER.

Aims & Methods

Thus, this study aimed to clarify clinicopathological characteristics of synchronous or metachronous multiple ESCCs missed by IEE but detected by LCE in surveillance endoscopy after esophageal ER. We retrospectively analyzed the consecutive lesions that fulfilled all of the following inclusion criteria: (1) treated with endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) at our institution between April 2021 and March 2022; (2) newly detected during surveillance endoscopy after ER or during preoperative endoscopy for other ESCC; (3) underwent narrow-band imaging (NBI) or blue laser imaging (BLI) observation followed by LCE observation in the esophagus using a high-definition endoscope at the endoscopic examination of lesion detection; and (4) biopsy-proven or strongly suspected squamous cell carcinoma. Patients with a history of chemotherapy, radiotherapy, or surgery for esophageal cancer were excluded. Lesions were classified into the IEE group (detected by NBI/BLI) and the LCE group (detected only after Lugol staining). The lesion in the IEE group were defined when the lesion was clearly visualized and in focus on the endoscopic images with NBI or BLI, or the endoscopic report described that it was detected with NBI/BLI. We evaluated the features of the lesions in the LCE group by comparing the clinicopathological characteristics between the lesions in the IEE group and LCE group. The endpoints were proportion of　LCE detected lesion and the proportion of target ESCC, defined as ESCC with pathological invasion depth of the muscularis mucosae (pT1a-MM) or deeper and/or positive lymphovascular invasion (LVI) on histological evaluation after ER.

Results

A total of 122 lesions in 96 patients were included. The IEE group comprised 99 lesions (81.1%) in 75 patients, while the LCE group comprised 23 lesions (18.9%) in 21 patients, thus proportion of LCE detected lesion was 18.9%. Most patients (92.7%, 89/96) had grade C of Lugol voiding staining. The median lesion size was 15 mm (range: 4-60 in the IEE group, which was higher than that in the LCE group at 10 mm (5-30). The lesions located on the anterior (23.5%) and left wall (31.3%) tended to be more frequently detected by LCE than those on the right (10.8%) and posterior wall (13.9%). Finally, 26 lesions were treated with EMR and 96 with ESD. The pathological diagnosis was pT1a-MM in 5 lesions and pT1b-SM1 in 2, resulting in the proportion of target ESCC of 5.7% (7/122). By group, the proportions of target ESCC were 7.1% (7/99) in the IEE group and 0% in the LCE group.

Conclusion

The characteristics of missed lesions in IEE observation tended to be small and located on the left or anterior wall of esophagus at surveillance endoscopy. Furthermore, all of these lesions were curatively resected with ER, resulting pT1a-EP/LPM without LVI in the pathological diagnosis.