Introduction

Endoscopic full-thickness resection (EFTR) is emerging as an effective and safe technique for difficult colorectal lesions, offering a valid alternative to surgery for “no-lifting” lesions, commonly performed during hospitalization. The recent outbreak of COVID-19 compelled endoscopic units to admit only patients for urgent endoscopic procedures, postponing hospitalization for elective non-life-saving procedures such as EFTR. Moreover, there has been growing experience supporting the safety and effectiveness of EFTR. We aim to retrospectively evaluate the safety and feasibility of non-exposed EFTR as an outpatient procedure in the main Italian centers.

Aims & Methods

We conducted a nationwide multicentre retrospective study, including 11 centers with demonstrated >5 years of expertise in non-exposed EFTR. The study is conceived as a collection of all consecutive cases of non-exposed colorectal EFTR for lesions <30 mm with “no lifting sign” or located in difficult anatomic locations, performed since 2018 in outpatient or hospital settings. “Hospital setting” is a hospital admission for clinical monitoring, including at least a one-night stay. “Outpatient setting” is defined as clinical monitoring that does not require the patient to stay overnight. The primary outcome was to compare the safety (defined as any adverse event rate) of EFTR between the hospital and outpatient groups. The Adverse Events (AEs) were classified as follows: mild (not requiring medical or endoscopic intervention), moderate (requiring medical or endoscopic intervention), and severe (requiring surgical therapy and/or potentially life-threatening.). Secondary outcomes were clinical success (histologically confirmed full-thickness R0 resection), technical success (ability to reach the target lesion), and recurrence rate at 12 months.

Results

One hundred-sixty-eight patients, 94 (55%) hospital setting, and 74 (45%) outpatient setting were included in the analysis. The two study groups were comparable for gender (male 59.6% vs 54.1%, p=0.47) and age (71.4±12.1 vs 68.4±11.1, p=0.1). There were no statistically significant differences among the groups for antiplatelet/coagulant therapy, lesion location, morphology, and size. No statistically significant differences in terms of mild AEs (2.1% vs 5.4%, p=0.41), moderate AEs (9.6% vs 9.5%, p= 0.98), and severe AEs (6.4% vs 1.4% p= 0.14) rate, technical success (96.8% vs 100%, p= 0.26), R0 resection rate (89.3% vs 87.8%, p= 0.78), technical difficulties (19.2% vs 27%, p= 0.23) and recurrence rate at 12 months (7.5% vs 4.2%, p=0.52) were observed between the two groups.

Conclusion

EFTR performed in an outpatient setting is safe and feasible with similar AEs and success rate to EFTR performed in a hospital setting. Thus, strict self-observation with the possibility to access directly to the endoscopic service allows adequate and cost-effective management for the post-EFTR AEs. Prospective studies are needed to confirm these results and demonstrate the safety and effectiveness of EFTR in this setting.

References

1. Gibiino G, Binda C, Papparella LG, Spada C, Andrisani G, Di Matteo FM, et al. Technical failure during colorectal endoscopic full-thickness resection: the "through thick and thin" study. Endoscopy. 2024;56(11):831-9.
2. Schmidt A, Beyna T, Schumacher B, Meining A, Richter-Schrag HJ, Messmann H, et al. Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications. Gut. 2018;67(7):1280-9.

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

Faecal microbial markers are emerging as valuable non-invasive tools for colorectal cancer (CRC) screening in average-risk populations. However, their utility in Lynch Syndrome (LS) carriers—a high-risk hereditary condition characterized by unique genetic and physiological features—remains largely unexplored.

Aims & Methods

This study investigates whether LS carriers exhibit distinct faecal microbial signatures compared to average-risk individuals, aiming to assess the potential of microbial markers to inform LS-specific surveillance strategies.
Faecal samples were collected from LS carriers undergoing routine surveillance colonoscopy and from participants in the Catalonia CRC screening program prior to screening colonoscopy. Quantitative PCR (qPCR) was employed to quantify selected bacterial markers: F. prausnitzii (FPRA), its phylogroups I (PHGI) and II (PHGII), P. stomatis (PTST), B. fragilis (BCTF), B. thetaiotaomicron (BCTT), B46 (best BLAST match: S. variable), G. morbillorum (GMLL), B48 (best BLAST match: Ruminococcus, Roseburia, and Coprococcus), E. coli (ECO), and Eubacteria (EUB) as total bacterial load. Participants from both cohorts were categorized by colonoscopy findings into normal colonoscopy (NC), non-advanced lesions (NAL), and advanced lesions (AL, including advanced adenomas and CRC). Statistical comparisons included t-tests and multivariate analysis of variance (MANOVA) following isometric log-ratio (ILR) transformation.

Results

LS carriers demonstrated significantly distinct faecal bacterial profiles relative to average-risk individuals, independent of lesion presence. Across the full cohort, LS carriers showed increased abundances of PTST (p<0.001), BCTT (p<0.001), B46 (p<0.001), and ECO (p<0.001), along with reduced levels of PHGI (p=0.017) and B48 (p=0.030).
In individuals with NC, LS carriers exhibited higher abundances of PTST (p<0.001), BCTT (p=0.010), B46 (p=0.025), ECO (p=0.017), and PHGI (p=0.041). Among those with NAL, LS carriers again presented higher abundances of BCTT (p=0.015), B46 (p<0.001), FPRA (p=0.012), ECO (p=0.043), and PHGI (p=0.024). In AL cases, LS carriers displayed a marked reduction in the abundance of BCTF (p<0.001) and an increase in the abundance of BCTT (p=0.043).
MANOVA analysis revealed significant differences in overall bacterial panel composition between LS carriers and average-risk individuals at each lesion stage (NC: p<0.001; NAL: p<0.001; AL: p=0.009).

Conclusion

LS carriers harbour a consistently distinct faecal bacterial profile compared to average-risk individuals, with differential abundance patterns evident across all stages of colorectal lesion development. These results highlight the importance of identifying and validating LS-specific bacterial markers, rather than extrapolating from average-risk cohorts, to enhance surveillance and early detection strategies tailored to this high-risk population.

Disclosure

S. Taboada-López, M. Malagón, L. Oliver, M. Serra-Pagès and S. Ramió-Pujol are employees of GoodGut.

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.