Clinical Case Summary

Achalasia is a rare esophageal motility disorder in children, with an estimated incidence of 0.02–0.11 per 100,000. The condition leads to failure of lower esophageal sphincter (LES) relaxation and absence of peristalsis, often resulting in feeding difficulties, vomiting, and growth retardation. Conventional treatments such as pneumatic balloon dilatation (PD) are often ineffective in very young children due to technical limitations and high recurrence rates. Peroral endoscopic myotomy (POEM) has emerged as a minimally invasive alternative, but data in the pediatric population, particularly in children under 3 years, are limited.
We present a 2-year-old boy with persistent vomiting, dysphagia, and failure to thrive. He weighed only 8 kg and had undergone two unsuccessful PD attempts. POEM was performed under general anesthesia using pediatric-modified technique: a 10-cm submucosal tunnel and 8-cm myotomy (5 cm selective, 3 cm full-thickness) were completed. Intraprocedural pneumoperitoneum was managed via Veress needle decompression. No complications occurred, and the child was discharged after 7 days. One month postoperatively, he gained 2 kg and achieved symptom resolution. Follow-up at 3 and 6 months showed continued weight gain and an Eckardt score improvement from 10 to 1.
This case highlights that POEM is feasible, effective, and safe even in very young and underweight children. It supports the expansion of POEM into earlier pediatric age groups, offering a durable alternative when conventional therapies fail.

References

1. Zhong C, Tan S, Huang S, et al. Clinical outcomes of peroral endoscopic myotomy for achalasia in children: A systematic review and meta-analysis. Dis Esophagus. 2021;34(4):1–11. doi:10.1093/dote/doaa112
2. Maselli R, Inoue H, Misawa M, et al. Peroral endoscopic myotomy (POEM) in a 3-year-old girl with severe growth retardation, achalasia, and Down syndrome. Endoscopy. 2012;44(Suppl 2):285–8. doi:10.1055/s-0032-1306696
3. Duman S, Yurci A, Cho JY. Peroral Endoscopic Myotomy (POEM) in a 19-Month-Old Girl with Primary Achalasia. J Dig Endosc. 2023;14(02):112–114. doi:10.1055/s-0043-1768544
4. Familiari P, Marchese M, Gigante G, et al. Peroral endoscopic myotomy for the treatment of achalasia in children. J Pediatr Gastroenterol Nutr. 2013;57(6):794–797. doi:10.1097/MPG.0b013e3182a80b13

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

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

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

Introduction

ESD allows en bloc resection of complex colorectal polyps. General anaesthetic (GA) for ESD is standard, requiring routine admission to hospital for monitoring. At our Trust conscious sedation is used preferentially. This study presents clinical outcomes of ESD performed in a high-volume tertiary centre in the UK using this approach.

Aims & Methods

• To evaluate the clinical outcomes of colorectal endoscopic submucosal dissection performed without general anaesthesia in a high-volume UK tertiary centre.
• To assess the feasibility and safety of ESD under conscious sedation or no sedation, with particular focus on rates of en bloc and R0 resection, adverse events, and post-procedural admissions.
• To identify clinical and procedural factors independently associated with incomplete (R1) resection following colorectal ESD.
• To compare outcomes between patients undergoing ESD with GA versus those without
Colorectal ESD procedures performed between 2018-2024 in a single centre in the UK were included. Data was retrospectively collected from the patient records. Multiple logistic regression was performed to identify independent factors associated with incomplete resection.

Results

A total of 147 patients (91 males ; median age 68 years) were included. Most polyps were rectal (100/150, 66.6%). Median polyp diameter was 42.5 mm.
GA was utilised in 13 patients, 80 had sedation alongside analgesia (median dose midazolam=2mg, fentanyl=100mcg) 44 required no IV sedation or analgesia, 8 had analgesia alone (median dose fentanyl 100mcg), 2 had sedation alone (median dose midazolam 0.75mg).
4 patients were admitted to hospital after their procedure and 14 were admitted within 30 days. There were 4 (2.7%) perforations and 7 (4.7%) post polypectomy bleeds (PPB).
Most procedures were complete ESD (109/147, 74.1%), the rest being hybrid ESD. R0 excision was achieved in 70/109 (64.2%) of those who had a complete ESD resection. No residual tissue was seen in patients with an R0 resection who had a subsequent LGI endoscopy (43/70). In those with R1 resection, a site check was undertaken at the same Trust in 59 patients. Residual tissue was seen in 7/59 (12%).
On univariate binomial regression, R1 resection was associated with polyps involving the dentate line [OR = 5.29 (95% CI = 1.84 – 17.8)], those with severe fibrosis [OR = 20.8 (95% CI = 3.85- 386.4)] and those receiving a GA [OR = 3.56 (95% CI = 1.06-16.3)]. On multivariate analysis, polyps involving the dentate line [OR = 8.17 (95% CI = 2.24 – 35.8)] and those with severe fibrosis [OR = 17.9 (95% CI = 2.57- 366.2)].

Table 1 - Outcomes of admissions following ESD

Conclusion

ESD is an effective treatment for high-risk complex colorectal polyps, able to provide high rates of en bloc resection. It can be achieved safely in most patients without GA. GA was associated with a higher rate of R1, however, this likely relates to these lesions being more complex.

Clinical Case Summary

A 46-year-old man from Bolivia consulted for abdominal pain with watery diarrhoea and occasional rectorrhagia for the last 2 months, associated with asthenia and weight loss. Laboratory tests showed microcytic anaemia, elevated C-reactive protein, positive faecal occult blood and negative stool culture. Colonoscopy (Images 1, 2) revealed deep ulcers in the ileum and colon with discontinuous areas of respected mucosa. Treatment was started with oral methylprednisolone at a dose of 1 mg/kg, with a decrease in the stool rhythm. He returned to the emergency department due to worsening abdominal pain, and was admitted for follow-up care. Histology (Image 3) showed epithelioid granulomas of probable infectious origin, due to the intramacrophagic inclusions, so the corticosteroid treatment was suspended. The quick test for HIV was positive, with a viral load of 79,000 copies/ml and a CD4 count of 88 CD4/ml. Mantoux and IGRA were negative. PCR amplification for Histoplasma spp in ileal biopsy was positive. Amphotericin B was prescribed with prophylaxis of opportunistic infections with trimethoprim-sulfamethoxazole. After 2 weeks, antiretroviral treatment was started. The patient improved, the abdominal pain disappeared and his intestinal rhythm normalised, and he was discharged from hospital. On outpatient follow-up, he was asymptomatic, with resolution of the ulcers in the control colonoscopy and no evidence of fungal structures in the histological examination.
The infection by Histoplasma capsulatum is the most frequent endemic mycosis in the American continent. Intestinal involvement is rare, with a preference for the ileocecal region in the form of deep ulcers that can simulate an outbreak of Crohn disease, as in our case. The use of immunosuppressants, especially anti-TNF-alpha, may worsen its course, highlighting the importance of a broad differential diagnosis, taking into account the patient's epidemiological characteristics.

References

Image 1. Colonoscopy. Terminal ileum with large ulcer with fibrin background, oedema and perilesional erythema.
Image 2. Colonoscopy. Transverse colon with two large deep ulcers with fibrin background and raised edges.
Image 3. Biopsy of ileum. Non-caseating epithelioid granulomas with intramacrophagic inclusions in ileal tissue. HE 40x.

Introduction

Sessile serrated lesions (SSLs), alongside adenomas, play a significant role in the development of colorectal cancer (CRC). Recent studies suggest that the adenoma detection rate (ADR) alone may not be sufficient for predicting post-colonoscopy CRC. Consequently, the ASGE/ACG Quality Task Force has recently recommended the sessile serrated lesion detection rate (SSLDR) as a new priority indicator for colonoscopy quality. Reviewing the variability of SSLDR in the control groups of previous randomized controlled trials (RCTs) may help identify factors that influence study outcomes.

Aims & Methods

A systematic review was conducted using PubMed, Embase, and the Cochrane Library databases to collect data from control groups of RCTs that assessed methods for increasing polyp detection with high-definition white-light colonoscopy (up to March 14, 2025). Random-effects meta-analysis pooled SSLDRs and their 95% confidence intervals (CIs). Heterogeneity was assessed with the I² statistic. Univariable and multivariable meta-regressions were performed to examine associations between SSLDR and study settings (publication year, sample size, number of centers, study design, and geographic origin), demographics (mean age, male proportion), and technical parameters (type of intervention, proportion of screening colonoscopy, ADR, and withdrawal time). This study was registered in PROSPERO (ID: CRD420251012475).

Results

A total of 23,461 patients from 48 studies were included in the analysis. SSLDR in the control arms ranged from 0.3% to 21.5%, with a pooled value of 4.4% (95% CI: 3.3%-5.8%; I² = 93%). Univariable meta-regression analysis identified patient age (OR 1.112; 95% CI: 1.043-1.186) and gender (OR 1.038; 95% CI: 1.003 to 1.074), geographic origin (OR 2.848; 95% CI: 1.585-5.116 for Europe and OR 4.044; 95% CI: 2.205-7.416 for North America), and ADR in the control arms (OR 1.054; 95% CI: 1.031-1.077) as significant predictors of SSLDR, with sample size (OR 0.999; 95% CI: 0.998-1.000) showing a negative correlation. Other factors, such as publication year, number of study centers (single or multiple), study design (parallel or tandem), type of intervention (imaging or mechanical), proportion of screening colonoscopy, and withdrawal time, had no significant effect. In multivariable meta-regression, RCTs conducted in Europe (OR 2.179; 95% CI: 1.242-3.820) and North America (OR 2.664; 95% CI: 1.550-4.580), as well as ADR in control arms (OR 1.035; 95% CI: 1.006-1.065), remained significant predictors of SSLDR, while sample size (OR 0.998; 95% CI: 0.997-0.999) and proportion of screening colonoscopy (OR 0.991; 95% CI: 0.983-0.998) were negatively correlated with SSLDR.

Conclusion

A high level of variability in SSLDR was found in the control groups of RCTs. Standardization of methodological and technical parameters is essential to improve the generalizability and reproducibility of findings from RCTs and enhance SSL detection in colonoscopy.