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OBJECTIVES: Colorectal carcinoma remains one of the most common malignancies worldwide. Colonoscopy screening is most effective for early detection and tumour prevention and is currently recommended in Europe for adults aged over 50 years. However, given that an increasing proportion of patients are diagnosed before the age of 50, we set out to determine the detection rate of colorectal carcinoma in patients younger than 50 years and to determine the best threshold for starting colonoscopy screening. METHODS: Single-centre, retrospective cohort study of all colonoscopies performed, regardless of indication, in our department at a tertiary Swiss university hospital in patients aged ≥18 and <60 years between 2016 and 2021. Colorectal cancer detection rate was calculated per 5-year age group and analysed separately by sex. RESULTS: The current analysis included 2846 colonoscopies performed for any indication. Colorectal carcinoma was found in 5/366 (1.4%) patients aged 45-49 years (3/210 or 1.4% of males and 2/156 or 1.3% of females) and in 9/819 (1.1%) patients aged 50-54 years (5/495 or 1.0% of males and 4/324 or 1.2% of females). Adenomas with high-grade dysplasia were found in 5/366 (1.4%) patients aged 45-49 years and in 11/819 (1.3%) aged 50-54 years; by sex, in 4/210 or 1.9% of males and 1/156 or 0.6% of females aged 45-49 years, and in 6/495 or 1.2% of males and 5/324 or 1.5% of females aged 50-54 years. Detection of adenoma with low-grade dysplasia increased from 14.6% (21/144) at age <30 years to 41% (150/366) at 45-49 years and 43.5% (356/819) at 50-54 years. A similar increasing trend was also seen if we analysed these groups by sex. CONCLUSIONS: The detection rate of colorectal carcinoma, but also adenomas, in our patients aged 45-49 years was similar to that in patients aged over 50, in both sexes. Thus our data are in line with the assumption that lowering the screening age to 45 years might be reasonable from a medical point of view for achieving a redu

PURPOSE: To assess the feasibility and performance of MR elastography (MRE) for quantifying liver fibrosis in patients with and without hepatic iron overload. METHODS: This retrospective single-center study analyzed 139 patients who underwent liver MRI at 3 Tesla including MRE (2D spin-echo EPI sequence) and R2* mapping for liver iron content (LIC) estimation. MRE feasibility and diagnostic performance between patients with normal and elevated LIC were compared. RESULTS: Patients with elevated LIC (21%) had significantly higher MRE failure rates (24.1% vs. 3.6%, p < 0.001) compared to patients with normal LIC (79%). For those with only insignificant to mild iron overload (LIC < 5.4 mg/g; 17%), MRE failure rate did not differ significantly from patients without iron overload (8.3% vs. 3.6%, p = 0.315). R2* predicted MRE failure with fair accuracy at a threshold of R2* ≥ 269 s$^{-1}$ (LIC of approximately 4.6 mg/g). MRE showed good diagnostic performance for detecting significant (≥ F2) and severe fibrosis (≥ F3) in patients without (AUC 0.835 and 0.900) and with iron overload (AUC 0.818 and 0.889) without significant difference between the cohorts (p = 0.884 and p = 0.913). For detecting cirrhosis MRE showed an excellent diagnostic performance in both groups (AUC 0.944 and 1.000, p = 0.009). CONCLUSION: Spin-echo EPI MRE at 3 Tesla is feasible in patients with mild iron overload with good to excellent performance for detecting hepatic fibrosis with a failure rate comparable to patients without iron overload.

BACKGROUND AND STUDY AIMS: Alveolar echinococcosis, an orphan zoonosis affecting the liver, is of increasing concern worldwide. Most symptomatic cases present at an advanced and inoperable stage, sometimes with biliary obstruction prompting biliary tract interventions. These are, however, associated with a high risk of infectious complications. The aim of this retrospective study was to compare the effectiveness and safety of conservative and interventional treatment approaches in patients with newly diagnosed alveolar echinococcosis and biliary obstruction. PATIENTS AND METHODS: Alveolar echinococcosis patients treated at two referral centres in Switzerland, presenting with hyperbilirubinaemia (total bilirubin >1.5 Upper Limit of Normal) at diagnosis were included, unless another underlying aetiology, i.e. common bile duct stones or decompensated cirrhosis, was identified. Patients were divided into two groups, according to whether they initially received a biliary tract intervention. The primary endpoint was normalisation of bilirubin levels within a 6-month period. Secondary endpoints included, among others, the occurrence of early and late biliary complications, the need for biliary tract interventions during follow-up and overall duration of hospital stays for treatment initiation and for biliary complications. RESULTS: 28 patients were included in this study, of whom 17 received benzimidazole therapy alone and 11 additionally received a biliary tract intervention. Baseline characteristics did not differ between groups. All but one patient in each group achieved the primary endpoint (p=0.747). Biliary tract intervention was associated with faster laboratory improvement (t1/2 1.3 vs 3.0 weeks), but also with more frequent early biliary complications (7/11 vs 1/17, p=0.002) and longer initial hospital stay (18 days vs 7 days, p=0.007). CONCLUSION: Biliary obstruction in patients with newly diagnosed alveolar echinococcosis can be treated effectively with benzimid

BACKGROUND We previously identified 16,772 colorectal cancer-associated hypermethylated DNA regions that were also detectable in precancerous colorectal lesions (preCRCs) and unrelated to normal mucosal aging. We have now conducted a study to validate 990 of these differentially methylated DNA regions (DMRs) in a new series of preCRCs. METHODS We used targeted bisulfite sequencing to validate these 990 potential biomarkers in 59 preCRC tissue samples (41 conventional adenomas, 18 sessile serrated lesions), each with a patient-matched normal mucosal sample. Based on differential DNA methylation tests, a panel of candidate DMRs was chosen on a subset of our cohort and then validated on the remaining part of our cohort and two publicly available datasets with respect to their stratifying potential between preCRCs and normal mucosa. RESULTS Strong statistical significance for the difference in methylation levels was observed across the full set of 990 investigated DMRs. From these, a selected candidate panel of 30 DMRs correctly identified 58/59 tumors (area under the receiver operating curve: 0.998). CONCLUSIONS These validated DNA hypermethylation markers can be exploited to develop more accurate noninvasive colorectal tumor screening assays.

BACKGROUND Fontan-associated liver disease is an increasing concern. Our aim was to assess prevalence and predictors of advanced liver fibrosis with a specific focus on utility of liver stiffness measurement by ultrasound transient elastography. METHODS 97 adult Fontan-patients (55% males, median age: 23.1 years, IQR: 18.7-30.6), 92 (95%) were evaluated with transient elastography and 50 (52%) underwent transjugular liver biopsy. Advanced liver fibrosis was defined as congestive hepatic fibrosis score 3 or 4. RESULTS Only four patients (4%) had liver stiffness values <10kPa. Liver stiffness measurements correlated weakly with peak oxygen uptake on exercise testing and Fontan-pressure but not with Model for End-stage Liver Disease excluding INR (MELD-XI)-score or spleen size. Serial follow-up liver stiffness measurements in 73 clinically stable patients showed large variability among individual patients. Advanced liver fibrosis was present in 35/50 (70%) patients on liver biopsy and was associated to MELD-XI-Score ≥11 and splenomegaly but not to liver stiffness measurements. Advanced liver fibrosis was not associated with patient age or time since Fontan-operation but with younger age at Fontan-completion (3.7 years, IQR: 2.3-6.3 versus 6.8 years, IQR: 3.5-12.1, p = 0.037). CONCLUSIONS In our cohort, advanced liver fibrosis was present in the majority of adult Fontan-patients. Liver stiffness as measured by transient elastography was not associated with the degree of liver fibrosis. Due to its high variability on serial measurements it seems not to be useful for clinical decision-making. The unexpected finding that younger age at Fontan-completion was associated with advanced liver fibrosis merits further evaluation.

BACKGROUND: Staging of liver fibrosis traditionally relied on liver histology, however transient elastography (TE) and more recently two-dimensional shear wave elastography (2D-SWE) evolved to non-invasive alternatives. Hence, we evaluated the diagnostic accuracy of 2D-SWE assessed by the Canon Aplio i800 ultrasound system using liver biopsy as reference and compared the performance to TE. METHODS: In total, 108 adult patients with chronic liver disease undergoing liver biopsy, 2D-SWE and TE were enrolled prospectively at the University Hospital Zurich. Diagnostic accuracies were evaluated using the area under the receiver operating characteristic (AUROC) analysis, and optimal cutoff values by Youden's index RESULTS: Diagnostic accuracy of 2D-SWE was good for significant (≥F2; AUROC 85.2%, 95% confidence interval (95%CI):76.2-91.2%) as well as severe fibrosis (≥F3; AUROC 86.8%, 95%CI:78.1-92.4%) and excellent for cirrhosis (AUROC 95.6%, 95%CI:89.9-98.1%), compared to histology. TE performed equally well (significant fibrosis: 87.5%, 95%CI:77.7-93.3%; severe fibrosis: 89.7%, 95%CI:82.0-94.3%; cirrhosis: 96%, 95%CI:90.4-98.4%), and accuracy was not statistically different to 2D-SWE. 2D-SWE optimal cutoff values were 6.5, 9.8 and 13.1 kPa for significant fibrosis, severe fibrosis, and cirrhosis, respectively. CONCLUSIONS: Performance of 2D-SWE was good to excellent and well comparable with TE, supporting the application of this 2D-SWE system in the diagnostic workup of chronic liver disease.

Previous data from short term studies have shown an efficacy of the duodenal-jejunal bypass liner (DJBL) for weight loss. However, less data is available regarding weight change after device removal and possible predictors for weight loss. This is a retrospective chart review of all patients who had DJBL inserted at the University Hospital Zurich between December 2012 and June 2015. A total of 27 patients had DJBL insertion. The median BMI at baseline was 38.5 (34.0-42.2) kg/m2 . In the 24 patients with DJBL treatment >3 months (failed implantation or early removal due to side effects in 3 patients), the mean duration of implantation was 42.9 ± 13.1 weeks. During the treatment, the mean total body weight loss (%TBWL) was 15.0 ± 8.3%. Fifteen patients had long-term follow-up data available (mean duration of follow-up 4.0 ± 0.9 years). The mean weight change was 12.7 ± 12.8 kg, corresponding with a mean % weight regain of 13.3 ± 13.3%. Five patients (33.3%) subsequently underwent bariatric surgery. In patients with class I obesity (BMI <35 kg/m2 at baseline), 4 out of 6 (66.7%) had a stable weight or only a weight regain <7%. In contrast, no patient with BMI >35 kg/m2 at baseline was able to keep weight regain below 7%. DJBL is an effective treatment for obesity, but substantial weight regain occurs during long-term follow up after the device removal, in particular in patients with BMI > 35 kg/m2 . Keywords: duodenal-jejunal bypass liner; obesity; obesity treatment; weight loss; weight maintenance.

Purpose: To compare the diagnostic performance of T1 mapping and MR elastography (MRE) for staging of hepatic fibrosis and grading inflammation with histopathology as standard of reference. Methods: 68 patients with various liver diseases undergoing liver biopsy for suspected fibrosis or with an established diagnosis of cirrhosis prospectively underwent look-locker inversion recovery T1 mapping and MRE. T1 relaxation time and liver stiffness (LS) were measured by two readers. Hepatic fibrosis and inflammation were histopathologically staged according to a standardized fibrosis (F0-F4) and inflammation (A0-A2) score. For statistical analysis, independent t test, and Mann-Whitney U test and ROC analysis were performed, the latter to determine the performance of T1 mapping and MRE for fibrosis staging and inflammation grading, as compared to histopathology. Results: Histopathological analysis diagnosed 9 patients with F0 (13.2%), 21 with F1 (30.9%), 11 with F2 (16.2%), 10 with F3 (14.7%), and 17 with F4 (25.0%). Both T1 mapping and MRE showed significantly higher values for patients with significant fibrosis (F0-1 vs. F2-4; T1 mapping p < 0.0001, MRE p < 0.0001) as well as for patients with severe fibrosis or cirrhosis (F0-2 vs. F3-4; T1 mapping p < 0.0001, MRE p < 0.0001). T1 values and MRE LS were significantly higher in patients with inflammation (A0 vs. A1-2, both p = 0.01). T1 mapping showed a tendency toward lower diagnostic performance without statistical significance for significant fibrosis (F2-4) (AUC 0.79 vs. 0.91, p = 0.06) and with a significant difference compared to MRE for severe fibrosis (F3-4) (AUC 0.79 vs. 0.94, p = 0.03). For both T1 mapping and MRE, diagnostic performance for diagnosing hepatic inflammation (A1-2) was low (AUC 0.72 vs. 0.71, respectively). Conclusion: T1 mapping is able to diagnose hepatic fibrosis, however, with a tendency toward lower diagnostic performance compared to MRE and thus may be used as an alternative to MRE for diagnos

Background: The perforated duodenal diverticulum remains a rare clinical entity, the optimal management of which has not been well established. Historically, primary surgery has been the preferred treatment modality. This was called into question during the last decade, with the successful application of non-operative therapy in selected patients. The aim of this systematic review is to identify cases of perforated duodenal diverticula published over the past decade and to assess any subsequent evolution in treatment. Methods: A systematic review of English and non-English articles reporting on perforated duodenal diverticula using MEDLINE (2008-2020) was performed. Only cases of perforated duodenal diverticula in adults (> 18 years) that reported on diagnosis and treatment were included. Results: Some 328 studies were identified, of which 31 articles met the inclusion criteria. These studies included a total of 47 patients with perforated duodenal diverticula. This series suggests a trend towards conservative management with 34% (16/47) of patients managed non-operatively. In 31% (5/16) patients initially managed conservatively, a step-up approach to surgical intervention was required. Conclusion: Conservative treatment of perforated duodenal diverticula appears to be an acceptable and safe treatment strategy in stable patients without signs of peritonitis under careful observation. For patients who fail to respond to conservative treatment, a step-up approach to percutaneous drainage or surgery can be applied. If surgery is required, competence in techniques ranging from simple diverticulectomy to Roux-en-Y gastric diversion or even Whipple's procedure may be required depending on tissue friability and diverticular collar size. Keywords: Duodenal diverticulum; Duodenum; Management; Perforation.

For patients after bariatric surgery, diagnosis of gastric cancer is a challenge. We present a patient after Roux-en-Y gastric bypass with upper abdominal pain and abnormal computed tomography scan with diffuse wall thickening of the gastric antrum. Various biopsy techniques have been described, with surgical (laparoscopic) exploration being the most common. We were able to successfully diagnose gastric cancer in the excluded stomach by biopsy using a jejunogastrostomy, which proved to be safe and effective.

Background: Time of diagnosis (TOD) of benign esophageal perforation is regarded as an important risk factor for clinical outcome, although convincing evidence is lacking. The aim of this study is to assess whether time between onset of perforation and diagnosis is associated with clinical outcome in patients with iatrogenic esophageal perforation (IEP) and Boerhaave’s syndrome (BS). Methods: We searched MEDLINE, Embase and Cochrane library through June 2018 to identify studies. Authors were invited to share individual patient data and a meta-analysis was performed (PROSPERO: CRD42018093473). Patients were subdivided in early (≤ 24 h) and late (> 24 h) TOD and compared with mixed effects multivariable analysis while adjusting age, gender, location of perforation, initial treatment and center. Primary outcome was overall mortality. Secondary outcomes were length of hospital stay, re-interventions and ICU admission. Results: Our meta-analysis included IPD of 25 studies including 576 patients with IEP and 384 with BS. In IEP, early TOD was not associated with overall mortality (8% vs. 13%, OR 2.1, 95% CI 0.8–5.1), but was associated with a 23% decrease in ICU admissions (46% vs. 69%, OR 3.0, 95% CI 1.2–7.2), a 22% decrease in re-interventions (23% vs. 45%, OR 2.8, 95% CI 1.2–6.7) and a 36% decrease in length of hospital stay (14 vs. 22 days, p < 0.001), compared with late TOD. In BS, no associations between TOD and outcomes were found. When combining IEP and BS, early TOD was associated with a 6% decrease in overall mortality (10% vs. 16%, OR 2.1, 95% CI 1.1–3.9), a 19% decrease in re-interventions (26% vs. 45%, OR 1.9, 95% CI 1.1–3.2) and a 35% decrease in mean length of hospital stay (16 vs. 22 days, p = 0.001), compared with late TOD. Conclusions: This individual patient data meta-analysis confirms the general opinion that an early (≤ 24 h) compared to a late diagnosis (> 24 h) in benign esophageal perforations, particularly in IEP, is associated with im

Enteral feed bezoars are difficult to treat and can lead to serious adverse events. There is no standardized treatment approach and various strategies have been suggested. We herein describe three cases of successful dissolutions of feed bezoars consisting of Promote® Fibre Plus with sodium bicarbonate 8.4% in critically ill patients. To provide the rationale for this approach, the effect of sodium bicarbonate 8.4% on enteral feed concretions was studied in vitro. First, Promote® Fibres Plus was incubated with hydrochloric acid with gradually decreasing pH values to establish a pH at which the solution solidifies. The resulting enteral feed concretion was exposed to sodium bicarbonate 8.4% and Coca Cola®. All patients were successfully treated with sodium bicarbonate 8.4% without the need of lengthy or repeat endoscopies. In vitro, Promote® Fibres Plus solidifies when acidified below a pH of 4.6. The resulting enteral feed concretions dissolved when exposed to sodium bicarbonate 8.4%. Incubation with Coca Cola® had no effect. We provide evidence that enteral feed bezoars consisting of Promote® Fibres Plus can be efficiently and safely treated with sodium bicarbonate 8.4% offering a new approach for daily patient care. Keywords: Enteral feed bezoar; Enteral feeding; Sodium bicarbonate.

Background Surgery is the cornerstone of esophageal cancer treatment but remains burdened with significant postoperative changes of gastrointestinal function and quality of life. Purpose The aim of this narrative review is to assess and summarize the current knowledge on postoperative functional syndromes and quality of life after esophagectomy for cancer, and to provide orientation for the reader in the challenging field of functional aftercare. Conclusions Post-esophagectomy syndromes include various conditions such as dysphagia, reflux, delayed gastric emptying, dumping syndrome, weight loss, and chronic diarrhea. Clinical pictures and individual expressions are highly variable and may be extremely distressing for those affected. Therefore, in addition to a mostly well-coordinated oncological follow-up, we strongly emphasize the need for regular monitoring of physical well-being and gastrointestinal function. The prerequisite for an effective functional aftercare covering the whole spectrum of postoperative syndromes is a comprehensive knowledge of the pathophysiological background. As functional conditions often require a complex diagnostic workup and long-term therapy, close interdisciplinary cooperation with radiologists, gastroenterologists, oncologists, and specialized nutritional counseling is imperative for successful management.

Introduction: Anastomotic leakage (AL) accounts for a significant proportion of morbidity following oesophagectomy. Endoluminal negative pressure (ENP) therapy via a specifically designed polyurethane foam (EsoSponge®, B.Braun Medical, Melsungen, Germany) has become the standard of care for AL in many specialized centres. The prophylactic (pENP) application of this technique aims to reduce postoperative morbidity and is a novel approach which has not yet been investigated in a prospective study. The aim of this study is therefore to assess the effect of pENP at the anastomotic site in high-risk patients undergoing minimally invasive transthoracic Ivor Lewis oesophagectomy. Methods and analysis: The study design is a prospective, multi-centre, two-arm, parallel-group, randomised controlled trial and will be conducted in two phases. Phase one is a randomised feasibility and safety pilot trial involving 40 consecutive patients. After definitive sample size calculation, additional patients will be included accordingly during phase two. The primary outcome of the study will be the postoperative length of hospitalization until reaching previously defined “fit for discharge criteria”. Secondary outcomes will include postoperative morbidity, mortality and postoperative AL-rates based on 90-day follow-up. A confirmatory analysis based on intention-to-treat will be performed. Ethics and dissemination: The ethics committee of the University of Zurich approved this study (2019-00562), which has been registered with ClinicalTrials.gov on 14.11.2019 (NCT04162860) and the Swiss National Clinical Trials Portal (SNCTP000003524). The results of the study will be published and presented at appropriate conferences.

With the advent of endoscopic full-thickness resection (EFTR), small subepithelial tumors (SETs) became easily resectable both in upper and lower gastrointestinal tract. Several studies have suggested that complete resection of SETs is achievable in the vast majority of cases and severe complications occur only rarely [1]. Whereas technical success in the case of mucosal or submucosal lesions is easy to accomplish, for tumors arising from the muscularis propria, an R0 resection is more difficult to achieve by EFTR [1]. Grasping these lesions with the Twin Grasper may lead to tenting of the mucosa and submucosa, which in turn leads to incomplete removal of the SET. To overcome this technical problem, we herein present the feasibility of EFTR using a tissue-retracting helix device that was originally designed as part of the OverStitch endoscopic suturing system (Apollo Endosurgery Inc., Austin, Texas, USA). We describe the case of a 75-year-old patient who was referred for removal of an incidental SET in the proximal gastric corpus. Endosonography suggested a small gastrointestinal stromal tumor (GIST) ([Fig. 1]). After the lesion had been marked ([Fig. 2 a]), the gastroduodenal EFTR device (Ovesco, Tübingen, Germany) was mounted onto the endoscope and the helix device was advanced through the working channel. Once the endoscope was centered over the lesion, it was gradually punctured with the helix; the device was then manually rotated (like a corkscrew), resulting in tissue approximation. After this “fixation” procedure, it was easy to retract the lesion into the cap using gentle suction. The SET was then resected in the usual fashion, with adequate closure of the resection site ([Fig. 2 b]; [Video 1]). The resected specimen ([Fig. 3]) was shown histologically to be a completely resected leiomyoma.

Die Endosonographie (EUS) in der Gastroenterologie hat sich von der rein diagnostischen Modalität zur vielversprechenden therapeutischen Disziplin gewandelt. Erster Schritt in diese Richtung war das EUS-gesteuerte Entnehmen von Gewebsproben an schwierig zugänglichen Lokalisationen; hier ist die Feinnadelpunktion von Pankreasläsionen an vorderster Stelle zu nennen. Mit dem EUS-gesteuertem Punktieren werden aber auch Gefässe erreicht, sodass Varizen gezielt verödet werden können. Kollektionen nach einer Pankreatitis werden ebenfalls minimal-invasiv angegangen und werden so nach luminal drainiert, statt eine chirurgische Intervention nötig zu machen. Durch das Einbringen von Führungsdrähten über die Hohlnadel sind zudem verschiedene Zugänge der Gallenwege intra- und extrahepatisch möglich, sodass interne Drainagen bei frustraner ERCP (endoskopische retrograde Cholangiopankreatikographie) möglich werden. Durch das Einbringen von speziell konfigurierten beschichteten Stents wiederum werden mit der interventionellen EUS neue Zugänge in Hohlorgane minimal-invasiv als Alternative zu chirurgischen Eingriffen geschaffen. Als Beispiel ist hier die endoskopische Gastroenterostomie bei maligner Magenausgangsstenose zu nennen.

Infectious complications are common adverse events of solid organ transplantation and immunosuppressive therapy. In the perioperative setting, most infections are of bacterial or viral origin. Risk assessment of donor and recipient focuses mostly on blood-borne pathogens. Occasionally, parasitic infections are reported after transplantation. In regard to the latter, we report the case of a 57-year-old patient who underwent simultaneous pancreas-kidney transplantation and shortly thereafter developed diarrhea, abdominal bloating and weight loss due to Giardia duodenalis.

Background/aims: Among the severe immune-related adverse events (irAEs) that occur with immune checkpoint inhibitor (ICI) therapy, colitis is the most frequent one. This study aimed at describing the experience from the largest gastroenterology unit in Switzerland with immune checkpoint inhibitor-associated colitis (ICIAC), its clinical presentation, management, and outcomes. Methods: We performed a retrospective review of patients who were referred for the evaluation of ICIAC between January 2011 and October 2018 to the Division of Gastroenterology and Hepatology, University Hospital Zurich. Results: Thirty-three patients with immune-related colitis grade 3 or 4 met the inclusion criteria and were analyzed in detail: All patients had diarrhea, 64% had abdominal pain, 42% had bloody stool, 27% had emesis, and 18% developed fever. In total, 33% were successfully treated with corticosteroids alone; 66% were steroid-refractory and treated with infliximab or vedolizumab. Two of these patients developed severe complications requiring surgery. All patients reached complete remission of ICIAC and its symptoms. At colonoscopy, ulcerations were seen in 37% of steroid-refractory versus 63% of steroid-responsive cases. Deep histological ulcerations invading the submucosa were only present in steroid-refractory cases. Conclusion: ICIAC is a severe irAE which frequently requires high-dose steroids and a close follow-up due to deleterious complications. The detection of histologically diagnosed deep ulcerations may predict a steroid-refractory course and may warrant early application of infliximab. However, larger studies are required to confirm our findings.

Checkpoint inhibitor-induced side effects such as diarrhea and colitis occur in up to 30% of patients. We present a case of recurrent episodes of checkpoint inhibitor-induced colitis and subsequent Fournier gangrene that resolved after ileostomy formation. Once the Fournier gangrene and colitis had resolved, the ileostomy was reversed. However, within only 4 days, another serious flare-up of colitis occurred, necessitating emergent re-formation of the ileostomy. Expertise in the management of side effects of immune checkpoint inhibitor therapy is currently limited. Although most side effects are mild to moderate and transient, a minority of patients suffer from life-threatening complications, such as colitis. The creation of an ileostomy might be a valid treatment option in severe or recurrent colitis due to immune checkpoint inhibitor therapy. Intestinal diversion surgery may be useful if conservative treatment has failed, similar to other forms of immune-mediated intestinal inflammation.

Biliary complications following liver transplantations, with leaks and bile duct strictures being the most common ones, are greatly feared. Portobiliary fistulas are rare, but may cause potentially life-threatening complications. The presented case shows the first successful treatment of a portobiliary fistula by an endoscopically deployed fully covered self-expandable metal stent after liver transplantation. In accordance to the already established use in refractory bile leaks, we believe that fully covered self-expandable metal stent is a safe and efficient treatment option for portobiliary fistula.

Purpose Anastomotic leakages or staple line defects after Roux-en-Y gastric bypass (RYGB) and primary laparoscopic sleeve gastrectomy (LSG), respectively, with consecutive bariatric revisional surgery are associated with relevant morbidity and mortality rates. Endoscopic vacuum therapy (EVT) with or without stent-over-sponge (SOS) has been shown to be a promising therapy in foregut wall defects of various etiologies and may therefore be applied in the treatment of postbariatric leaks. Methods We report the results of six consecutive patients treated with EVT (83% in combination with SOS) for early postoperative leakages in close proximity to the esophagogastric junction (EGJ) after LSG (n = 2) and RYGB (n = 4) from May 2016 to May2018. Results All patients (2/6 male, median age 51 years, median BMI 44.2 kg/m2) were treated successfully without further signs of persisting leakage at the last gastroscopy. The lesions’ size ranged from 0.5 cm2 to 9 cm2, and the leaks were connected to large (max. 225 cm2) abscess cavities in 80% of the cases. Median duration of treatment (= EVT in situ) was 23.5 days (range, 7–89). The number of endoscopic interventions ranged from 1 to 24 (median, n = 7), with a median duration between vacuum sponge replacements of 4 days. Conclusion EVT is an effective and safe treatment for staple line defects or anastomotic leakage after bariatric surgeries and can therefore be adopted for the treatment of midgut wall defects. Further studies with a greater number of patients comparing surgical drainage alone or in combination with EVT versus EVT alone are needed.

Acute gastrointestinal bleeding represents a common medical emergency. We report the rare case of acute upper gastrointestinal bleeding caused by varices in the gastric fundus secondary to splenic duplication. Splenic duplication has been only rarely reported in the literature, and no case so far has described the associated complication of gastrointestinal bleeding, caused by venous drainage of the upper spleen via varices in the gastric fundus. We describe the imaging findings from endoscopy, endosonography, computed tomography (CT), flat-panel CT, and angiography in this rare condition and illustrate the effective role of intra-arterial embolization

Over-the-scope-clips (OTSC(®)) have been shown to be an effective and safe endoscopic treatment option for the closure of gastrointestinal perforations, leakages and fistulae. Indications for endoscopic OTSC(®) treatment have grown in number and also include gastro cutaneous fistula (GCF) after percutaneous endoscopic gastrostomy (PEG) tube removal. Non-healing GCF is a rare complication after removal of PEG tubes and may especially develop in immunosuppressed patients with multiple comorbidities. There is growing evidence in the literature that OTSC(®) closure of GCF after PEG tube removal is emerging as an effective, simple and safe endoscopic treatment option. However current evidence is limited to the geriatric population and short standing GCF, while information on closure of long standing GCF after PEG tube removal in a younger population with significant comorbidities is lacking. In this retrospective single-center case-series we report on five patients undergoing OTSC(®) closure of chronic GCF after PEG tube removal. Four out of five patients were afflicted with long lasting, symptomatic fistulae. All five patients suffered from chronic disease associated with a catabolic metabolism (cystic fibrosis, chemotherapy for neoplasia, liver cirrhosis). The mean patient age was 43 years. The mean dwell time of PEG tubes in all five patients was 808 d. PEG tube dwell time was shortest in patient 5 (21 d). The mean duration from PEG tube removal to fistula closure in patients 1-4 was 360 d (range 144-850 d). The intervention was well tolerated by all patients and no adverse events occured. Successful immediate and long-term fistula closure was accomplished in all five patients. This single center case series is the first to show successful endoscopic OTSC(®) closure of long lasting GCF in five consecutive middle-aged patients with significant comorbidities. Endoscopic closure of chronic persistent GCF after PEG tube removal using an OTSC(®) was achieved in all patient

A 74-year-old woman with extensive lichen planus mucosae (LPM) developed stenotic esophagitis that was refractory to intravenous glucocorticosteroids. Esophageal dilatations to 14 mm width were repeatedly performed without any lasting effect. After introducing oral apremilast, she experienced complete clinical remission within the first 4 weeks of treatment. Control esophagoscopy confirmed a marked recovery of the esophageal mucosa with no recurrence of the former stenosis. Our observation is in line with the case series of Paul et al. [J Am Acad Dermatol 2013;68: 255–261] who first reported on the benefit of apremilast in patients with extensive LPM. Ideally, the effectiveness of apremilast in LPM should be studied in a randomized controlled trial.

BACKGROUND/AIMS To identify the number and potential causes of unnecessary diagnostic procedures in a cohort of patients with autoimmune pancreatitis (AIP). METHODS All AIP cases at our centre between April 2006 and April 2013 were collected and followed up. Diagnosis was established by the International Consensus Diagnostic Criteria (ICDC). Demographic, clinical, radiological, serological data, the number of diagnostic procedures and the reason for referral were recorded. Possible risk factors for a delayed diagnosis of AIP were analysed. RESULTS A total of 29 patients (median age 60 years; 22 males and 7 females) were diagnosed with AIP using ICDC. Twenty-five patients were diagnosed with definite, 2 with possible type 1 AIP and 2 with type 2 AIP. In 29 patients, 50 ERCPs and 18 EUS were carried out; based on ICDC recommendations, a total of 20 ERCPs and 4 EUS were unnecessary diagnostic procedures. Eight patients (23.0%) were referred for unnecessary surgery. Jaundice was shown to be a significant risk factor for unnecessary endoscopic investigations (OR 11.00, 95% CI 1.14-106.43, p = 0.04). CONCLUSION Diagnosis of AIP still remains a challenge. Patients with jaundice are at particular risk of being subjected to unnecessary endoscopic procedures. Use of ICDC would help avoid unnecessary examinations or even major surgeries at times.

BACKGROUND: Management of leakages of the gastrojejunal anastomosis after laparoscopic Roux-en-Y gastric bypass (LRYGB) can be complex. New endoscopic techniques such as covered stents and over-the-scope clips (OTCs) have been developed and are valuable alternative therapeutic options to reoperation and drainage. The aim of this study was to compare the value of stents and OTCs with surgical treatment options for the therapy of anastomotic leakages after LRYGB. METHODS: Results of patients who were treated surgically with reoperation, local irrigation and drain placement (n = 9) were compared with results of patients who were treated endoscopically with stent and/or OTC placement (n = 5). Success rate, length of hospital stay, mortality, number of OTC applications/stent placement and percutaneous drainage placements were analyzed. RESULTS: Overall, 14 of 1,046 patients (1.34%) developed a leakage of their gastrojejunal anastomosis after LRYGB between 2000 and 2012. While the success rate in surgically treated patients was 88%, the endoscopic treatment using a sequential approach with stenting, OTC application and percutaneous placement of drainages resulted in a 100% closure rate. The mortality rate and length of stay were not substantially different after both treatment regimens. CONCLUSION: Endoscopic management of anastomotic leakages after LRYGB may constitute a valuable alternative therapeutic option to surgical reoperation and drainage placement.

Hemospray (Cook Medical, Winston-Salem, North Carolina, USA) is a hemostatic agent recently introduced for the management of upper gastrointestinal bleeding (GIB). To date, there is little experience with this fairly new hemostatic tool. The aim of this case series was to reflect the use and effectiveness of Hemospray as a treatment option in GIB in everyday clinical practice at two tertiary referral centers. Consecutive patients (n = 16) with active GIB of various origins were treated with Hemospray. The rate of successful initial hemostasis was 93.75 % (15 /16; salvage therapy 92.85 % [13/14]; monotherapy 100 % [2 /2]). The rebleeding rate within 7 days was 12.5 % (2/16). One patient, in whom interventional radiology also failed, had to undergo surgery as salvage therapy. The effectiveness of Hemospray in the management of GIB in various clinical situations is promising. Future multicenter randomized prospective trials for clearly defined bleeding situations are needed for greater generalizability of case series findings.

OBJECTIVE: To date, there is no standardized treatment for esophageal perforations and leakages caused by underlying benign diseases, and it is still debated whether a conservative, endoscopic treatment or a surgical approach is preferable. However, some cases series have successfully demonstrated the feasibility of a temporary placement of self-expanding stents. DESIGN: All patients with benign leakages of the esophagus or gastroesophageal junction or fistulas at gastroesophageal anastomosis were collected during the past 12 years and analyzed retrospectively. The patients treated with endoscopic stenting were analyzed for sustained success, complications, time to stenting, lesion size, number of stents used, need for percutaneous drainage. RESULTS: Eighty-five of eight-eight patients were included in this analysis. Three patients were conservatively managed only. The success rate of stent treatment with an average of 1.3 stents was 79%. Success was highest (94%, n = 30 of 32, no complications or mortality) in iatrogenic lesions that were immediately diagnosed and treated. Spontaneous lesions, including lesions due to Boerhaave's syndrome, were healed in 73% and anastomotic leakages were closed in 71%. Fistula had a lower success rate of 43%. Use of multiple stents sequentially placed was necessary in 23% of the cases. Percutaneous drainage was necessary in 25% of all cases. CONCLUSION: Temporary stent placement for benign leakages of the esophagus is safe and seems to improve treatment success. Adjacent fluid collections should be drained percutaneously.

OBJECTIVE: Optimal endoscopic treatment of gastric varices is still not standardized nowadays. Actively bleeding varices may prohibit a successful endoscopic injection therapy of Histoacryl® (N-butyl-2-cyanoacrylate). Since 2006, we have treated gastric varices by standardized endoscopic ultrasound (EUS) guided Histoacryl injection therapy without severe adverse events. MATERIAL AND METHODS: We present a large single-center cohort over 7 years with a standardized EUS-guided sclerotherapy of all patients with gastric varices. Application was controlled by fluoroscopy to immediately detect any glue embolization. Only perforating veins located within the gastric wall were treated. In the follow up, we repeated this treatment until varices were eradicated. RESULTS: Utmost patients (36 of 40) were treated during or within 24 h of active bleeding. About 32.5% of patients were treated while visible bleeding. Histoacryl injection was always technically successful and only two patients suffered a minor complication. Acute bleeding was stopped in all patients. About 15% (6 of 40) of patients needed an alternative rescue treatment in the longer course. Three patients got a transjugular portosystemic shunt and another three underwent an orthotopic liver transplantation. Mean long-term survival of 60 months was excellent. CONCLUSION: Active bleeding of gastric varices can be treated successfully without the necessity of gastric rinsing with EUS-guided injection of Histoacryl.

BACKGROUND: Therapy-resistant lichen planus (LP) can be a challenging condition for dermatologists. There are some case reports about successful treatments with alitretinoin of cutaneous and oral, but not of esophageal LP. OBJECTIVE: We present the unique case of a patient with cutaneous, oral and esophageal LP which was refractory to classical treatment options (topical clobetasol propionate and pimecrolimus, intramuscular triamcinolone acetonide); because of systemic side effects the patient did not tolerate systemic acitretin dosed up to 25 mg daily. Methods: Oral alitretinoin was used at a dose of 30 mg daily. RESULTS: Both oral and skin changes as well as dysphagia completely resolved within 4 weeks without any severe side effects and the drug was used for 6 months. No papules, intraoral striae or dysphagia recurred during the 6 months of treatment. After 4 months the patient relapsed with mucosal patches so that a second cycle was initiated for 6 months where oral LP lesions resolved after 4 weeks also (with sporadic mild headache). CONCLUSION: Further studies are needed to better understand the impact of alitretinoin in LP. Our observation suggests alitretinoin as a new, well-tolerated treatment option for esophageal LP after failed response to conventional treatments.

Despite the increasing use of carbon dioxide for endoscopies during the last years, ambient air is still used. The amount of air depends on several factors such as examination time, presumable diameter of the endoscope channel and of course active use of air by the operator. Although endoscopic complications due to ambient air in the gastrointestinal (GI) tract are a rare observation and mostly described in the colon, we report five cases in the upper GI tract due to insufflating large amounts of air through the endoscopes. All 5 patients needed an emergency upper endoscopy for acute presumed upper GI bleeding. In two cases both esophageal variceal bleeding and ulcer bleeding were detected; the fifth case presented with a bleeding due to gastric cancer. Due to insufflation of inadequate amounts of air through the endoscope channel, all patients deteriorated in circulation and ventilation. Two rumenocenteses and consecutively three laparotomies had to be performed in three patients. In the other two, gastroscopies had to be stopped for an emergency computed tomography. All critical incidents were believed to be a consequence of a long-lasting examination with use of too much air. Therefore in emergency situations, endoscopies should be performed with either submersion, low air flow pumps or even better by the use of carbon dioxide.

These patients showed focal liver lesions, to be considered in the differential diagnosis of cirrhotic livers. Infarcted regenerative nodules may be underdiagnosed in patients with decompensation of cirrhosis. In order to differentiate these lesions from malignant tumors, serial imaging seems to be helpful. However, the main differential diagnosis should be an abscess. It is important to know the wide spectrum of image appearances of these lesions. Hypotension can lead to a reduction of portal and arterial liver flow. Since variceal bleeding or septic shock can induce hypotension - as observed in our patients - we conclude that this leads to infarction of such nodules.

Acute gastrointestinal bleeding represents a common medical emergency. We report the rare case of acute upper gastrointestinal bleeding caused by varices in the gastric fundus secondary to splenic duplication. Splenic duplication has been only rarely reported in the literature, and no case so far has described the associated complication of gastrointestinal bleeding, caused by venous drainage of the upper spleen via varices in the gastric fundus. We describe the imaging findings from endoscopy, endosonography, computed tomography (CT), flat-panel CT, and angiography in this rare condition and illustrate the effective role of intra-arterial embolization