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

Clinical Case Summary

Aims: We report 3 cases of new inflammatory bowel disease (IBD) which occurred in multiple sclerosis (MS) patients undergoing ocrelizumab therapy over last year in Irish Teaching Hospital setting.
Background: Ocrelizumab, a monoclonal antibody targeting CD20-positive B cells, is an established treatment for MS. While it is generally well-tolerated, emerging reports suggest a possible link to gastrointestinal complications, including IBD.
Methods: Three MS patients presented after starting ocrelizumab with gastrointestinal symptoms suggestive of inflammatory bowel disease. They were fast-tracked for endoscopic evaluation by an experienced gastroenterologist specializing in IBD. Diagnosis was based on clinical presentation, endoscopic findings, and histological analysis. Data regarding symptom onset, disease severity, colitis grade, inflammation distribution, and treatment response were assessed.
Results: A temporal relationship was observed between ocrelizumab initiation and IBD onset in all three cases, with symptoms emerging after 4-6 infusions. Reported symptoms included diarrhoea, nausea, urgency, and abdominal pain. Faecal calprotectin levels at time of referral ranged from 900 to 1800 µg/g. Endoscopy confirmed mild colitis and terminal ileitis, while histology revealed active colitis with cryptitis, acute terminal ileitis, or normal colon findings. Treatment with steroids, Mesalazine, and antibiotics led to symptom resolution in all cases. Discontinuing ocrelizumab resulted in recovery within 4-6 weeks, with no relapse over an average follow-up of two months.
Conclusion: These cases suggest a potential association between ocrelizumab and IBD onset or exacerbation in MS patients. Symptom resolution upon drug withdrawal supports a possible causal relationship. Clinicians should be aware of this risk to facilitate early detection, management, and patient education.

References

https://journals.lww.com/acgcr/Fulltext/2022/01000/Severe_Ocrelizumab_Induced_Enterocolitis_Treated.31.aspx
https://pubmed.ncbi.nlm.nih.gov/32198886/

Disclosure

No Conflict of Interest