Clinical Case Summary

Gastrointestinal neuroendocrine tumours (NETs) are low-grade malignant tumours in the GI tract. They account for 0.4% to 1.8% of GI malignancies. Duodenal NETs are relatively rare tumours and only accounts for 2% to 3% of GI NETs.
The patient, a 68 year old male, had dyspepsia and OGD showed a 10mm subepithelial lesion (SEL) (Insert image here) in the second part of the duodenum. Biopsies revealed polypoid foveolar hyperplasia. An endoscopic ultrasound (EUS) was done to evaluate the SEL which showed a 7mm x 8mm hypoechoic lesion within the submucosal layer (insert image). There was a slit within the SEL which corresponds to the previous biopsy sampling. Differentials were GIST or pancreatic rest. Further biopsies were taken from the within the slit which concluded as a well-differentiated NET, Grade 1.
PET DOTATE scan showed tracer-avid focus in the duodenum. Chromogranin A was elevated at 1056ug/L.
In view of previous sampling with a biopsy scar now, removal of the duodenal NET was carefully thought out. Endoscopic mucosal resection (EMR) has a higher risk of perforation due to the possibility of fibrosis from the biopsies. Laparoscopic endoscopic cooperative surgery was discussed with the surgeons, however, it is invasive.
Patient then underwent underwater EMR. The duodenal NET had sufficient buoyancy whilst underwater (Insert image). A 10mm snare was used, and polypectomy with Endocut Q mode done with good margins. There was no intraprocedural bleeding nor perforation. Two clips were used to close the polypectomy site prophylactically (Insert image).
Histology demonstrated tumour cells within the lamina propria and submucosa with salt and pepper like chromatin and round nuclei. They were positive for synaptophysin and chromogranin. Ki-67 index was 2%, and the margins were clear. This was conclusive of a NET Grade 1.
This case highlights the approach and differentials to duodenal lesions, and points to be considered for endoscopic resection in the duodenum.

References

Sato Y, Hashimoto S, Mizuno K, Takeuchi M, Terai S. Management of gastric and duodenal neuroendocrine tumors. World J Gastroenterol. 2016 Aug 14;22(30):6817-28
Gaspar JP, Stelow EB, Wang AY. Approach to the endoscopic resection of duodenal lesions. World J Gastroenterol. 2016 Jan 14;22(2):600-17
Wang X, Wu Y, Cao X, Zhang X, Cheng Y, Kong L. Duodenal neuroendocrine tumor: A rare case report. Medicine (Baltimore). 2021 Feb 12;100(6):e24635
Milione M, Parente P, Grillo F, Zamboni G, Mastracci L, Capella C, Fassan M, Vanoli A. Neuroendocrine neoplasms of the duodenum, ampullary region, jejunum and ileum. Pathologica. 2021 Feb;113(1):12-18

Introduction

Nowadays, endoscopic treatment for esophageal Zenker's diverticulum is considered the standard of care, with flexible endoscopic septotomy (FES) being the first technique to be widely adopted. Since 2016, submucosal tunneling Per-Oral Endoscopic Myotomy (Z-POEM) has emerged as an innovative therapeutic approach. However, medium-term efficacy comparisons between Z-POEM and FESremain limited.

Aims & Methods

The aim of this study was to compare the clinical success and safety of Z-POEM and FES.
This study was a retrospective analysis of a large group of patients treated for Zenker's diverticulum across two tertiary care centers. The patients were divided into two groups: those who underwent Z-POEM between 2021 and 2024, and those who underwent FES between 2008 and 2024. Demographic and clinical data, including Charlson Comorbidity Index, Kothari scores, clinical success rates, adverse events, and follow-up duration, were analyzed and compared among the two groups.

Results

Treatment in the study period. Of these, 32 patients (mean age 66.8 ± 10.7 years) underwent Z-POEM, while 34 patients (mean age 73.5 ± 10.2 years) underwent FES. The mean Charlson Comorbidity Index was similar between groups (Z-POEM: 3.28 ± 1.80 vs. FES: 3.4 ± 1.6; p = 0.708). The pre-procedural Kothari-Haber score was comparable (mean 7.3 ± 1.4 for Z-POEM vs. 7.3 ± 1.1 for FES; p= 0.981). The post-procedural Kothari-Haber score was significantly lower in the ZPOEM group (1.3 ± 1.3) compared to the FES group (2.7 ± 2.8; p = 0.010), indicating better symptom resolution. The median follow-up period was 37.7 months (IQR: 14.8 – 74.6 months) for the FES group and 12.2 months (IQR: 7.4 – 21.9 months) for the Z-POEM group (p < 0.0001). Technical success was achieved in 100% in both groups. Clinical success was significantly higher in the Z-POEM group (93.8%; 95% CI: 75% - 99%) compared to the FES group (64.5%; 95% CI: 50% - 82%; p= 0.005). The rate of adverse events was lower in the Z-POEM group (6.25%) compared to the FES group (23.53%), however this difference did not reach statistical significance (p= 0.084).

Conclusion

This multicenter retrospective study suggests that Z-POEM is an effective and safe alternative to FES for the treatment of Zenker’s diverticulum. The Z-POEM technique demonstrated a significantly higher clinical success rate and a trend towards fewer adverse events. Of particular interest, no differences in terms of efficacy and adverse events were observed between the first 10 patients (during the learning curve) treated with Z-POEM and those treated thereafter. It should be noted that although the follow-up period for Z-POEM was generally shorter, no recurrence of symptoms was observed even in patients with longer follow-up durations. These findings support the use of Z-POEM as a viable and effective approach, warranting further investigation in larger multicenter cohorts to confirm its advantages.

References

Bizzotto A, Iacopini F, Landi R, Costamagna G. Zenker's diverticulum: exploring
treatment options. Acta Otorhinolaryngol Ital. 2013 Aug;33(4):219-29. PMID:
24043908; PMCID: PMC3773964.
Elkholy S, El-Sherbiny M, Delano-Alonso R, et al . Peroral endoscopic myotomy as treatment for Zenker's diverticulum (ZPOEM):
a multi-center international study. Esophagus. 2021 Jul;18(3):693-699. doi:
10.1007/s10388-020-00809-7. Epub 2021 Jan 2. PMID: 33387150.
Kahaleh M, Mahpour NY, Tyberg A, et al. Per Oral Endoscopic Myotomy for Zenker's
Diverticulum: A Novel and Superior Technique Compared W ith Septotomy? J Clin
Gastroenterol. 2022 Mar 1;56(3):224-227. doi: 10.1097/MCG.0000000000001579.
PMID: 34183618.
Steinw ay S, Zhang L, Amundson J, Nieto J, Desai P, Jacques J, Bejjani M, Pioche M,
Kumta N, Hernandez-Mondragon O, Ujiki M, Khashab M. Long-term outcomes of
Zenker's peroral endoscopic myotomy (Z-POEM) for treatment of Zenker's
diverticulum. Endosc Int Open. 2023 Jun 29;11(6):E607-E612. doi: 10.1055/a-2067-
9105. PMID: 37397859; PMCID: PMC10310448.
Sw ei, E., Pokala, S.K., Menard-Katcher, P. et al. Comparison of Zenker’s per-oral
endoscopic myotomy (Z-POEM) w ith standard flexible endoscopic septotomy for
Zenker’s diverticulum: a prospective study w ith 2-year follow -up. Surg Endosc 37,
6818–6823 (2023). https://doi.org/10.1007/s00464-023-10136-4

Disclosure

Giuseppe Grande is consultant for Olympus, Boston Scientific, ERBE, Fujifilm

Introduction

Fecal microbiota transplantation (FMT) is an established treatment for Clostridium difficile infection (CDI) and is increasingly explored for other conditions such as inflammatory bowel disease (IBD), autism spectrum disorder (ASD), and metabolic syndromes. Various FMT delivery methods exist, including colonoscopy, enema, nasogastric tube, and oral capsules, with colonoscopy often preferred for its high success rates. This study aimed to assess the safety profile of FMT administered via colonoscopy in pediatric patients.

Aims & Methods

Fecal microbiota transplantation (FMT) has been established as an effective treatment for Clostridium difficile infection (CDI) and is being increasingly explored for other conditions, including inflammatory bowel disease (IBD), autism spectrum disorder (ASD), and metabolic disorders. Various administration routes exist, with colonoscopy often preferred for its efficacy. This study aims to assess the safety profile of FMT via colonoscopy in pediatric patients since data in pediatric population is scarce.
We conducted a retrospective, single-center study at Vilnius University Hospital Santaros Klinikos, reviewing all pediatric FMT procedures performed between 2017 and 2024. Patient data, including demographic information, clinical indications, and post-procedure outcomes, were collected from medical records. All procedures adhered to institutional safety protocols.

Results

A total of 108 FMT procedures were performed on 73 pediatric patients (52 male, 21 female), with a median age of 8.8 years (range: 2.7–17.8 years). The primary indications for FMT included ASD - as part of an ongoing biomedical research (n=84, 77.8%), CDI (n=11, 10.2%), IBD (n=7, 6.5%), and other conditions (n=6, 5.6%). Among CDI cases, 81.8% were associated with underlying IBD. No complications related to anesthesia or the colonoscopy procedure were observed, and no serious adverse events occurred. Mild, self-limiting adverse events, such as transient diarrhea and abdominal discomfort, were reported in 10 cases (9.3%). One patient (0.9%) experienced fever and pharyngitis three days post-procedure, though this was deemed unrelated to FMT.

Conclusion

Our findings suggest that FMT via colonoscopy is a well-tolerated and safe procedure in pediatric patients, with no significant complications and only occasional mild, transient adverse effects. These results support the continued use of FMT as a safe therapeutic option in pediatric care.