Introduction

Lynch Syndrome (LS), the most common hereditary colorectal cancer (CRC) syndrome, is associated with increased adenoma and carcinoma risks. Colonoscopy surveillance recommendations generally consider MMR gene-specific risk but remain largely standardized in terms of surveillance intensity and frequency. However, accumulating evidence suggests that genotype-specific differences in neoplasia risk may warrant more tailored approaches.

Aims & Methods

This study evaluated trends in adenoma and CRC incidence across surveillance visits stratified by genotype among LS patients. We analyzed 318 LS patients with pathogenic variants in MLH1, MSH2, MSH6, PMS2 or EPCAM each with ≥2 surveillance colonoscopies between 2015–2025 at MD Anderson Cancer Center in Texas, USA. Individuals with prior colorectal surgery, inflammatory bowel disease, incomplete colonoscopy, or sigmoidoscopy-only exams were excluded. Adenoma (tubular, tubulovillous [TVA], SSA) and advanced neoplasia (advanced adenoma or CRC) rates were assessed over three follow-up visits. Statistical comparisons used Kruskal-Wallis and Fisher’s exact tests (α=0.05).

Results

Among 205 patients with follow-up (median age 43.4, median follow-up 1089 days), tubular adenomas (TA) were observed in 58.8%, sessile serrated adenomas (SSA) in 16.2%, and advanced neoplasia (AN) in 7.8%. Five CRCs (2.4%) were identified overall. MSH2/EPCAM carriers (n=79) had the highest neoplasia burden, with TA in 57.0%, SSA in 20.3%, and 3 of 5 CRCs. MLH1 carriers (n=50) had TA in 43.4%, SSA in 2.0%, and 2 CRCs (4.0%). PMS2 (n=37) had the lowest burden (TA 21.6%, SSA 5.4%) and no CRCs. While per-visit incidence trends were not statistically significant, total adenoma count across genotypes differed significantly (p<0.05). Additionally, TA and TVA incidence at first follow-up varied significantly by genotype (p = 0.036 and 0.037, respectively).

Table: Neoplasia Outcomes by LS Genotype (n = patients with ≥1 follow-up)

Conclusion

These findings highlight important genotype-specific differences in cumulative adenoma and CRC burden among LS carriers. While MSH2/EPCAM and MLH1 carriers exhibited the highest neoplasia rates, PMS2 carriers demonstrated consistently low lesion and cancer incidence. These results support the need for genotype-based surveillance strategies to reduce unnecessary procedures while preserving cancer prevention.

Disclosure

The authors declare that they have no conflicts of interest related to this work.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is widely used for biliary diseases, yet safety data in transplant recipients remain scarce.

Aims & Methods

This study aimed to evaluate short-term survival and ERCP-related complications in transplant patients. We conducted a retrospective cohort study using the TriNetX database (December 2020–December 2024). Patients diagnosed with acute cholangitis who underwent ERCP were included. Transplant recipients were matched 1:1 with non-transplant controls without active cancer using propensity score matching. Outcomes assessed included survival (Kaplan-Meier analysis) and ERCP-related complications such as post-ERCP pancreatitis (PEP), sepsis, perforation, retroperitoneal abscess, liver abscess, blood transfusion, and emergency department visits.

Results

Before matching, 2,209 transplant recipients and 41,202 non-transplant controls met the inclusion criteria. After propensity score matching, 1,710 matched pairs were analyzed. Survival rates were comparable between transplant and non-transplant groups. Transplant recipients had significantly lower rates of PEP (HR: 0.591, 95% CI: 0.371–0.943, p=0.0254) and emergency department visits (HR: 0.667, 95% CI: 0.498–0.893, p=0.0061). Rates of other complications were not significantly different: sepsis (HR: 1.183, 95% CI: 0.799–1.754, p=0.4005), retroperitoneal abscess (HR: 1.514, 95% CI: 0.587–3.906, p=0.3468), liver abscess (HR: 1.377, 95% CI: 0.826–2.293, p=0.2176), perforation (HR: 2.088, 95% CI: 0.793–5.493, p=0.1272), and blood transfusions (HR: 1.642, 95% CI: 1.255–2.147, p=0.0003). Subgroup analysis of liver transplant patients showed lower PEP rates (HR: 0.592, 95% CI: 0.347–1.009, p=0.0510), but higher risks of retroperitoneal abscess (HR: 3.499, 95% CI: 0.976–12.544, p=0.0402), liver abscess (HR: 2.682, 95% CI: 1.303–5.521, p=0.0053), and blood transfusions (HR: 1.797, 95% CI: 1.282–2.518, p=0.0005).

Conclusion

ERCP appears safe in transplant recipients, demonstrating comparable short-term survival and overall complication rates to non-transplant patients. However, careful monitoring for post-ERCP bleeding and infections is particularly warranted in liver transplant recipients.

References

1. O'Connor HJ, Vickers CR, Buckels JA, McMaster P, Neuberger JM, West RJ, Elias E. Role of endoscopic retrograde cholangiopancreatography after orthotopic liver transplantation. Gut. 1991 Apr;32(4):419-23. doi: 10.1136/gut.32.4.419. PMID: 2026341; PMCID: PMC1379083.
2. Predictors of Early Repeat Endoscopic Retrograde Cholangiopancreatography After Liver Transplantation by Organ Donor TypeSinha, Jasmine et al. Techniques and Innovations in Gastrointestinal Endoscopy, Volume 24, Issue 2, 159 - 166

Introduction

Studies report that almost 50% of Large Non-Pedunculated Colorectal Polyps (LNPCP) have been subjected to heavy manipulation in form of prior attempts at resection or extensive biopsy sampling prior to referral to an expert centre. This significantly impacts several critical outcomes of endoscopic resection (ER). However, understanding of standardised classifications of LNPCP, endoscopic diagnosis and indications for ER has increased in general endoscopy practice which may have improved decision making prior to referral. We aimed to compare trends in patterns of prior injudicious manipulation and the significance of biopsy sampling over sequential time periods in a large cohort of patients referred to a tertiary referral centre for ER.

Aims & Methods

Referral documentation, including clinic and referral letters, endoscopy reports, and histopathology result, were reviewed for evidence of prior resection attempts or biopsy sampling. Data included the number of biopsy samples taken and corresponding histological results. Patients referred between January 2011 and August 2024 were categorised into five time periods. Heavy manipulation was defined as either a prior resection attempt or ≥6 biopsy samples. Analyses included comparisons of resection attempts, heavy manipulation, biopsy sampling, and the detection of high-grade dysplasia on biopsies (as a marker of improved lesion assessment and targeted sampling). Trends in practice changes were assessed using the Chi-square test for trend.

Results

1407 LNPCP were treated by ER. There was a significant trend toward fewer prior failed attempts at resection over sequential time periods with 30% in Period 1 and only 11% in Period 5 (p<0.001); fewer LNPCP subjected to heavy manipulation with 61% in Period 1 and 27% in Period 5 (p<0.001) and fewer LNPCP with prior biopsy sampling with 77% in Period 1 and 47% in Period 5 (p<0.001). However, there was no trend found for an improvement in biopsy sampling yields of HGD with 18% in Period 1 and 25% in Period 5 (p=0.1).

Conclusion

In a large cohort of ER of LNPCP, this study demonstrates a significant reduction over time in failed resection attempts, heavy manipulation, and biopsy sampling of LNPCP before referral to a tertiary centre for endoscopic resection (ER). This suggests an improvement in endoscopic lesion assessment and decision making by general endoscopists. However, heavy manipulation remains a significant problem. Although fewer LNPCP are biopsied prior to referral, the yield of significant findings did not change, suggesting biopsies are not effectively targeted, and highlighting the need for further improvements in lesion assessment.

Introduction

EUS-hepatico-gastrostomy(HGS) has become indispensable procedure in case of inaccessible cases due to malignant invasion to the duodenum etc. , failed ERCP cases, and failed cases after single balloon assisted ERCP(SBE-ERCP) in surgical altered anatomy.

Aims & Methods

From January, 2016 to April, 2024, we have performed EUS-HGS in 131(Male:79, Female 52, averaged age: 72) cases. The indication of EUS-BD was inaccessible to the duodenal papilla due to malignant invasion or failed cases of ERCP in cases of normal anatomy. In cases without duodenal invasion and intrahepatic bile duct dilatation, we perform EUS-CDS and we perform EUS-BD rendezvous in cases of accessible normal anatomy. And we performed EUS-HGS in remained cases. In surgical anatomy cases, we firstly perform SBE-ERCP, EUS-HGS were performed after failed SBE-ERCP. We have investigated the safety and usefulness of HGS.

Results

The subjects were consisted of malignant diseases (pancreatic cancer: 61(46.6%), biliary cancer: 20(15.3%), and others 35(26.7%) and benign disease (stenosis of bilio-jejunum anastomosis 7(5.3%), bile duct stone7(5.3%), primary sclerosing cholangitis 1(0.8%)). The reason for EUS-HGS were consisted of duodenal invasion 84 (64.1%) cases, inaccessible 21(16%), failed deep canulation 20(15.3%), others 6(4.6%). And normal anatomy cases were 90 (68.7%) and surgical anatomy 41(31.3%). Technical and clinical success was 128(97.7%) and 116(88.5%). The median procedure duration was 36 minutes (range 11-109). The used needle was 19 guage: 113(86.3%) and 22 guage: 18(13.7%). The puncturing branch was B3: 95(72.5%), B2: 35(26.7%), and B1: 1(0.8%). The averaged size of punctured branch was 5.0mm (range2.0-13.0). The dilation method was bougie: 97(74%), balloon: 21(16%), electrocautery: 6(4.6%), drill dilator: 5(3.8%), and not dilate: 2(1.5%). The used stent was plastic stent (PS): 105(80.2%) and covered metallic stent (CMS): 24(18.3%). The stent patency was PS: 120 days and CMS: 226 days (p=0.13). The early complication was peritonitis: 10(7.6%), bacteremia: 5(3.8%), cholangitis: 4(3.1%), bleeding: 2(1.5%), and migration: 3(2.3%). The multivariate analysis revealed only longer procedure duration (more than 36 min.) corelated to early complication(p=0.01).

Conclusion

EUS-HGS is safe and effective and essential for inaccessible cases, failed cases after ERCP and SBE-ERCP. And longer procedure duration corelated with early complication.

Introduction

Endoscopic Papillectomy (EP) represents the gold standard treatment for ampullary adenoma. Despite high rates of clinical success, EP is still burdened by a non-negligible rate of adverse events, with bleeding being one of the most frequent, with a reported pooled rate of 10.6%. Despite differences in presentation and in severity, the majority of the EP-related bleeding can be managed endoscopically. Various techniques, including epinephrine injection, argon plasma coagulation (APC), hemoclips, biliary stents have been employed to manage bleeding, but robust evidence supporting their efficacy are still lacking. Recently, the introduction of a novel haemostatic peptide gel has expanded the toolbox of endoscopic haemostatic agents.

Aims & Methods

This study aims to evaluate the safety and efficacy of this new haemostatic agent in controlling bleeding in patients undergoing EP. This is a multicenter, retrospective study from 4 high-volume centers in Italy, including all consecutive patients treated with the novel heamostatic peptide gel for the management of active EP-related bleeding, between 2019 and 2024. Clinical success was defined as the achievement of hemostasis using the hemostatic gel, either alone or in combination with other techniques, for the treatment of active intraprocedural or delayed EP-related bleeding, without subsequent rebleeding

Results

A total of 16 patients were included in the study. In 15 patients, haemostatic gel was used to manage intraprocedural bleeding, while one patient was treated for delayed bleeding. An oozing bleeding was shown in 13 cases, a spurting bleeding in one case, while in 3 cases no active bleeding was present, although a visible vessels was found in two patients and one ulcer with an adherent clot in one case. Six patients were treated exclusively with haemostatic gel, while the remaining patients received combination treatments, including epinephrine injection (5 cases), clipping (6 cases), biliary stenting (2 cases), and fibrin glue application (1 case). The application of hemostatic gel was successful in 100% of cases, despite the use of side-viewing duodenoscopes with elevator. Clinical success of haemostatic gel application after the first bleeding episode was achieved in 75% (12/16) of patients. However, 4 out of 16 patients (25%) experienced rebleeding within one day after the first treatment. The severity of bleeding ranged from mild to moderate, effectively controlled endoscopically in all cases except one, in which a radiologic embolization was needed in order to achieve bleed control and was therefore classified as severe. No gel-related adverse events were reported.

Conclusion

This novel peptide gel could represent a promising and safe tool to manage active bleeding related to EP. Further prospective studies are needed to confirm its efficacy.

References

Vanbiervliet G, et al. Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53: 429–448.
Spadaccini M, et al. Endoscopic papillectomy for neoplastic ampullary lesions: A systematic review with pooled analysis. United Eur Gastroenterol J 2020; 8: 44–51.
Choi JH, et al. Bleeding after endoscopic papillectomy and its risk factors: A single center experience of 196 cases. Hepatobiliary Pancreat Dis Int 2024; S1499387224000237.
Nam K, et al. Usefulness of argon plasma coagulation ablation subsequent to endoscopic snare papillectomy for ampullary adenoma. Dig Endosc 2018; 30: 485–492.
Hyun JJ, et al. A prospective multicenter study of submucosal injection to improve endoscopic snare papillectomy for ampullary adenoma. Gastrointest Endosc 2017; 85: 746–755.
Park SW, et al. Effect of prophylactic endoscopic clipping for prevention of delayed bleeding after endoscopic papillectomy for ampullary neoplasm: a multicenter randomized trial. Endoscopy vol. 54,8 (2022): 787-794.
Subramaniam S, et al. A novel self-assembling peptide for hemostasis during endoscopic submucosal dissection: a randomized controlled trial. Endoscopy 2021; 53: 27–35.
Maselli R, et al. Efficacy of novel endoscopic hemostatic agent for bleeding control and prevention: Results from a prospective, multicenter national registry. Endosc Int Open. 2024 Oct 28;12(10):E1220-E1229.