Introduction

Surgery is the standard treatment for colorectal cancer (CRC). Following the introduction of screening programs for CRC, a substantial shift toward the diagnosis of CRC at an earlier stage is observed (1). In T1 CRC merely 10% of carcinomas have spread to lymph nodes or distant organs (2), suggesting that a vast majority of T1 CRC can be successfully treated with a minimal invasive approach. Endoscopic treatment for early CRC (pT1), rather than surgical resection, is expected to reduce mortality, morbidity and costs (3, 4). We evaluated oncological outcomes and patient safety of endoscopic resection of suspected pT1 CRC in a Norwegian CRC screening centre.

Aims & Methods

From January 2020 until November 2022, we prospectively registered all endoscopic procedures performed for suspected pT1 CRC. We recorded endoscopic technique, optical evaluation, pathology results, staging using CT and MRI, additional surgery as well as complications and final outcome. All patients were informed about the advantages and potential risks of endoscopic treatment vs. surgical resection, and all gave informed consent before treatment after shared decision-making. All patients were discussed at our multidisplinary team (MDT) meeting.

Results

A total of 42 suspected T1 CRC cases treated endoscopically were included. 95% (38/40) of the lesions were identified as possibly malignant with optical evaluation (JNET 2B/NICE III/SANO IIIa) before treatment. 62% (26/42) of patients were deemed to have completed treatment with endoscopic resection. Sixteen patients underwent surgery following endoscopic treatment after discussions in the MDT meeting. Of these, three had lymph node metastasis, one of these had both lymph node metastasis and residual disease; at the site of the primary tumor. All three patients had one or more histopathological risk factors (one T2 stage + lymphovascular invasion (LVI) + poor differentiation, one T1 with LVI, one T1 with Rx and LVI). The remaining 13 patients (81% of those operated) had no residual disease and were thus overtreated. No severe adverse events were recorded, and no patients needed hospitalization with intensive care treatment.

Conclusion

Our study suggests that endoscopic treatment of suspected early-stage CRC is efficient and safe.

References

1. Cardoso R, Guo F, Heisser T, Hackl M, Ihle P, De Schutter H, et al. Colorectal cancer incidence, mortality, and stage distribution in European countries in the colorectal cancer screening era: an international population-based study. Lancet Oncol. 2021;22(7):1002-13.
2. Ichimasa K, Kudo S-E, Miyachi H, Kouyama Y, Misawa M, Mori Y. Risk Stratification of T1 Colorectal Cancer Metastasis to Lymph Nodes: Current Status and Perspective. Gut and Liver. 2021;15(6):818-26.
3. Vermeer NCA, Backes Y, Snijders HS, Bastiaannet E, Liefers GJ, Moons LMG, et al. National cohort study on postoperative risks after surgery for submucosal invasive colorectal cancer. BJS open. 2018;3(2):210-7.
4. Ma C, Teriaky A, Sheh S, Forbes N, Heitman SJ, Jue TL, et al. Morbidity and Mortality After Surgery for Nonmalignant Colorectal Polyps: A 10-Year Nationwide Analysis. Am J Gastroenterol. 2019;114(11):1802-10.

Disclosure

Michael Bretthauer Olympus, Cybernet, Paion
Svein Oskar Frigstad Takeda, Galapagos, Jansen-Cilag, Abbvie, Pharmacosmos, Norgine and Bristol-Myers-Squibb

Introduction

Individuals with Disorders of Gut-Brain Interaction (DGBI) may experience avoidant/restrictive food intake disorders (ARFID). However, these findings have been limited to specialist neurogastroenterology clinics. We assessed the association between ARFID and DGBI within the adult general population.

Aims & Methods

A population-based Internet survey with pre-defined demographic quotas was conducted across the UK and USA in 2023. The survey included the Rome IV diagnostic questionnaire for DGBI, the nine-item ARFID screen (NIAS), and questions regarding demographics, body mass index, non-GI somatic symptoms, anxiety and depression, quality of life, and healthcare utilisation.

Results

4002 adults (mean age 47 [range 18-91] years, 50% females) completed the survey, of whom 1704 (42.6%) had symptoms compatible with at least one DGBI.
The prevalence of ARFID-positive screens was significantly higher among participants with DGBI compared to those without DGBI (34.6% vs. 19.4%, OR 2.2), with similar findings noted in each country. Among participants with DGBI, positive ARFID screens by NIAS subscale were poor appetite (21.5%), picky eating (18.1%) and a fear of aversive consequences (9.9%).
ARFID was present in 42.1% of those with oesophageal DGBI, 49.2% with gastroduodenal DGBI, 33.1% with bowel DGBI, and 41.8% with anorectal DGBI. The presence of ARFID among the two widely investigated DGBI, i.e. functional dyspepsia and IBS, was 56.2% and 50.4%, respectively.
The presence of ARFID increased with the number of DGBI regions, ranging from 19.4% in those with no DGBI, 27.5% with DGBI in one region, 40.0% for DGBI in two regions, 49.7% for DGBI in three regions, and 61.1% for DGBI in four regions (p<0.001). A positive correlation was seen between the number of DGBI regions and the severity of ARFID (r=0.29, p<0.001).
Individuals with DGBI plus ARFID, compared to those with only DGBI, were significantly more likely to be underweight (7.9% vs. 1.5%), have greater non-GI somatic symptoms and mood disturbances, reduced mental and physical quality of life, and increased GI healthcare visits; all p<0.001.

Conclusion

Positive ARFID screens are common in DGBI and associated with increased general health burden. Routine screening for ARFID in DGBI will inform the multi-integrated care plan provided by clinicians, dietitians, and psychologists.

Disclosure

Nil

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:
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Disclosure

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