Clinical Case Summary

The syndrome of buried lumen-apposing metal stents (LAMS) occurs in 4.7% of cases and is caused by a foreign body reaction characterised by tissue overgrowth embedded in the stent. This complication often requires surgery or "stent-in-stent" endoscopic procedures (1). Stent in a stent safely and effectively recanalises LAMS placed as esophagogastric anastomosis (2), gallbladder drainage (3), and endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE) (4). We report the first EUS-directed transenteric ERCP (EDEE) case using this approach. In 2023 a patient with Roux-en-Y hepaticojejunostomy (HJ) substenosis and recurrent cholangitis was admitted to our institution. The first attempt to perform an EUS-guided gastrojejunostomy (GJ) as part of EDEE failed; EUS -Hepaticogastrostomy (HGS) was conducted. One month later, a Hot-Axios LAMS (15mm x 15mm) EUS-GJ was placed, and prior 15 mm balloon dilatation, the second part of the EDEE operation was conducted, accessing the surgical HJ with a paediatric colonoscope and placing a Nagi stent (16mm x 20mm) towards the substenosis. The LAMS completely buried itself during the 6-month Nagi removal follow-up, making it impossible to determine its gastric mucosal location. We placed a fully covered self-expandable metal stent (10mm x 8cm) on the HGS for antegrade Nagi stent extraction. Recurrent HJ substenosis and bile duct stones induced cholangitis in 2024. EUS-guided identification and cannulation of the buried LAMS involved passing a 19-G fine needle biopsy needle through the LAMS, advancing a Jagwire deep into the jejunum, and bridging it with a second Hot-Axios LAMS (15mm x 15mm) using a non-cautery enhanced (cold LAMS-in-LAMS) technique.A frontal scope was used to remove bile duct stones before the latest 15 mm balloon was expanded, and a third 15 mm x 10 mm LAMS was placed across the substenotic HJ. EUS-guided management of buried LAMS was safe and effective, with normal liver function tests and clinical outcomes.

References

1) Nayar, M., Leeds, J. S., UK & Ireland LAMS Colloborative, & Oppong, K. (2022). Lumen-apposing metal stents for drainage of pancreatic fluid collections: does timing of removal matter?. Gut, 71(5), 850–853. https://doi.org/10.1136/gutjnl-2021-325812
2) Bazaga Pérez de Rozas, S., Chahal, P., Sánchez-Ocaña, R., García-Alonso, F. J., Carbajo, A. Y., de la Serna-Higuera, C., & Manuel, P. M. (2019). Buried lumen-apposing metal stent (LAMS) in esophagogastric anastomosis: the LAMS-in-LAMS rescue treatment. Endoscopy, 51(6), 600–601. https://doi.org/10.1055/a-0861-99074)
3) Ligresti, D., Cipolletta, F., Amata, M., Cimavilla, M., Traina, M., & Tarantino, I. (2018). Buried lumen-apposing metal stent (LAMS) following endoscopic ultrasound-guided gallbladder drainage: the LAMS-in-LAMS rescue treatment. Endoscopy, 50(8), 822–823. https://doi.org/10.1055/a-0624-2050
4) Honan, B. M., Mulki, R., & Sánchez-Luna, S. A. (2024). Bridging the Buried GATE: LAMS-in-LAMS Rescue Technique for Endoscopic Ultrasound-Directed Transgastric ERCP. ACG case reports journal, 11(9), e01497. https://doi.org/10.14309/crj.0000000000001497

Clinical Case Summary

A 62-year-old woman with hypothyroidism and multiple sclerosis presented to our care to underwent outpatient esophagogastroduodenoscopy (EGD) after one episode of hematemesis, which had occurred 20 days earlier following the use of Naproxen (440 mg/day) for low back pain. Proton pump inhibitor (PPI) therapy had been initiated afterward. EGD revealed a 20 mm ulcer in the gastric body with an adherent clot. Upon gastric distension, oozing bleeding from the ulcer was observed and treated with adrenaline injection and endoscopic clips. Diffuse oozing from the gastric mucosa and multiple suction-related hematomas were also noted. The patient was hospitalized and started on high-dose intravenous PPI therapy and fasting. H. pylori serology was negative. Physical exam showed hepatomegaly and lower limb edema. Lab tests revealed elevated cholestatic enzymes, proteinuria, leukocytosis, hypoalbuminemia, mild anemia, and a monoclonal spike on serum protein electrophoresis. Abdominal ultrasound confirmed hepatomegaly. Autoimmune, viral, and metabolic liver diseases were excluded. Liver magnetic resonance raised suspicion of a storage disorder. Liver biopsy confirmed AL-type amyloid deposits. A follow-up EGD was performed, in absence of further GI bleeding, to obtain gastric biopsies. It showed a 1 cm ulcer with an adherent clot in the fundus. Again, insufflation triggered diffuse oozing from the ulcer and gastric mucosa with suction-related hematomas. Histology confirmed amyloid deposits. Suspecting multiple myeloma, immunofixation identified Bence-Jones proteinuria and hypergammaglobulinemia. Spinal MRI showed vertebral collapse at D12–L1; cardiac MRI excluded cardiac involvement. MM with secondary AL amyloidosis was diagnosed. Treatment with targeted therapy led to symptom resolution.This case highlights the importance of considering rare systemic diseases in atypical GI bleeding, especially when triggered by minimal stimuli such as gastric distension.

References

1. Histological images of liver and stomach with amyloid deposits.
2. Endoscopic images of gastrointestinal bleeding manifestations in patients with gastric amyloidosis

Introduction

The incidence of rectal neuroendocrine neoplasms (R-NENs) has been increasing annually. While most R-NENs are solitary, multiple lesions are relatively rare. Previous studies have suggested that patients with ≥8 lesions are more likely to exhibit lymphatic invasion and metastasis, indicating higher risk. However, the clinical and pathological features, prognosis, and endoscopic treatment outcomes of multiple R-NENs remain poorly understood. This study aimed to clarify the clinical characteristics and endoscopic treatment efficacy of multiple R-NENs through a retrospective analysis of cases from our hospital, providing evidence for clinical management.

Aims & Methods

This retrospective study included 28 patients with multiple R-NENs treated endoscopically at the Cancer Hospital of the Chinese Academy of Medical Sciences between January 2010 and January 2024. Patients were divided into two groups based on lesion count: the "several group" (n < 8) and the "numerous group" (n ≥ 8). All patients underwent preoperative imaging to exclude lymph node metastasis and distant metastases. Data on demographics, lesion characteristics, endoscopic procedures, pathological findings, and follow-up outcomes were collected and analyzed.

Results

We compared endoscopic treatment outcomes between patients with several (＜8, n=24) and numerous (≥8, n=4) rectal neuroendocrine tumors. The numerous group had a larger median maximum diameter (9.50 mm vs. 6.00 mm, p=0.337) and included one G2 case (25.0%) versus none in the several group, though differences were not significant. Notably, endoscopic complete resection was achieved in 100% of patients in both groups. All other parameters, including margin positivity, vascular invasion, neural invasion, and R0 resection rate, showed no significant differences. However, the numerous group had a significantly higher recurrence rate (75.0% vs. 0%, p=0.001). These findings highlight lesion count as a critical prognostic indicator for recurrence after endoscopic treatment.

Conclusion

Patients with ≥8 rectal neuroendocrine tumors exhibited more aggressive disease behavior, characterized by higher recurrence rates. These findings underscore the importance of lesion count as a prognostic indicator and suggest that patients with ≥8 lesions may require more intensive follow-up and management. For patients with <8 lesions, endoscopic treatment is effective when lymph node and distant metastases are excluded preoperatively. Future studies with larger datasets are needed to validate these findings and explore optimized treatment strategies.

Disclosure

The authors declare no conflicts of interest in relation to this study.

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

Emerging experimental and clinical data suggest that the gut microbiome can significantly influence the antitumor efficacy of key chemotherapy agents, including 5-fluorouracil, oxaliplatin, and docetaxel. These agents form the backbone of the neoadjuvant chemotherapy (NAC) regimen, FLOT, which is widely used for the treatment of locally advanced gastric cancer (GC). However, despite growing evidence from preclinical models, clinical studies investigating the direct association between gut microbiome composition and the response to NAC in GC patients remain scarce.

Aims & Methods

This study aims to address this gap in knowledge by exploring the relationship between the gut microbiome and therapeutic outcomes in this clinical context. In this longitudinal observational study, we explored the association between pre-treatment fecal microbiome composition analyzed via 16S rRNA gene sequencing and histological tumor regression, as assessed by the Becker score, in GC patients undergoing NAC with the FLOT regimen, followed by gastrectomy.

Results

Among the 38 enrolled patients, 19 (50%) achieved a Becker score of 1–2 and were classified as ‘Responders,’ while the other 19 (50%) were classified as ‘Non-responders’. Responders exhibited a higher abundance of Parabacteroides distasonis, Alistipes sp. AL-1, and Bacteroides plebeius. A combined biomarker of these species demonstrated robust predictive accuracy for a favorable response to NAC, with sensitivity of 89%, specificity of 63%, and an AUC of 0.8 (95% CI: 0.66–0.94). In contrast, non-responders showed a predominance of bacterial genera, including Ruminococcaceae UCG-014, Ruminococcus 1, Ruminococcaceae UCG-005, and the [Eubacterium] eligens group. The combined biomarker of these genera demonstrated excellent predictive performance for poor NAC response, with sensitivity of 89%, specificity of 95%, and an AUC of 0.93 (95% CI: 0.85–1.0).

Conclusion

The results of our study support the hypothesis that the pre-treatment gut microbiome composition can serve as a reliable biomarker for predicting both positive and negative responses to NAC in GC patients. By identifying specific microbial signatures associated with chemotherapy outcomes, this research provides critical insights into how microbiome-based strategies might enhance personalized treatment regimens for GC. Future studies are needed to validate these findings and explore potential therapeutic interventions targeting the microbiome to improve clinical outcomes in GC patients.

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