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Conventional endoscopic mucosal resection (CEMR) is the standard modality for removing non-pedunculated colorectal lesions. Underwater endoscopic mucosal resection (UEMR) has emerged as an alternative method. There are few comparative studies between these techniques, especially evaluating recurrence. Then, the purpose of this trial was to compare CEMR and UEMR for the resection of colorectal lesions with respect to efficacy, safety and recurrence rate.Randomized controlled trial of UEMR versus CEMR for naïve and non-pedunculated lesions measuring between 10 and 40 mm. The primary outcome was adenoma recurrence at 6 months after the resection. Secondary outcomes were technical success, en bloc resection and adverse events rates. Block randomization was used to assign patients. Tattooing was performed to facilitate localization of the scars and eventual recurrences. Endoscopic follow-up was scheduled at 6 months after the procedure. The sites of resections were examined with white light, Narrow-Band Imaging and conventional chromoscopy with indigo carmine followed by biopsies.One hundred and five patients with 120 lesions were included, with a mean size of 17.5 ± 7.1 (SD) mm. Sixty-one lesions were resected underwater and 59 by CEMR. The groups were similar at baseline, regarding age, gender, average size, or histological type. Lesions in the proximal colon in the conventional group corresponded to 83% and in the UEMR group to 67.8% (p=0.073). There was no difference between groups regarding success rate (one failure in each group) and en bloc resection rate (60.6% UEMR vs 54.2% CEMR, p = 0.48). Intra-procedure bleeding was observed in five conventional resections (8.5%) and two UEMRs (3.3%) (p = 0.27). There was no perforation or delayed hemorrhage in both groups. Recurrence rate was higher in the CEMR arm (15%) than in UEMR (2%) (p=0.031). Therefore, the relative risk of 6-month recurrence rate in the CEMR group was 7.5 fold higher (95% CI - 0.98 to 58.20) with a NNT of 7.7 (95% CI - 40.33 to 4.22). The higher recurrence rate in CEMR group persisted only for lesions measuring 21-40mm (35.7 vs. 0%, p=0.04).This study demonstrated that UEMR was associated with lower adenoma recurrence rate than CEMR. Both endoscopic techniques are effective and have similar rates of adverse events for the treatment of non-pedunculated colorectal lesions.

Background Although endoscopic vacuum therapy (EVT) has been successfully used to treat postoperative upper gastrointestinal (UGI) wall defects, its use demands special materials and several endoscopic treatment sessions. Herein, we propose a technical modification of EVT using a double tube (tube-in-tube drain) without polyurethane sponges for the drainage element. The tube-in-tube drainage device enables irrigation and application of suction. A flowchart for standardizing the management of postoperative UGI wall defects with this device is presented. Methods An EVT modification was made to achieve frequent fistula cleansing, with 3 % hydrogen peroxide rinsing, and the application of negative pressure. A tube-in-tube drain without polyurethane sponges can be inserted like a nasogastric tube or passed through a previously positioned surgical drain. This was a retrospective two-center observational study, with data collected from 30 consecutive patients. Technical success, clinical success, adverse events, time under therapy, interval time from procedure to fistula diagnosis and treatment start, size of transmural defect, volume of cavity, number of endoscopic treatment sessions, and mortality were reviewed. Results 30 patients with UGI wall defects were treated. The technical and clinical success rates were 100 % and 86.7 %, respectively. Three patients (10 %) had adverse events and three patients (10 %) died. The median time under therapy was of 19 days (range 1–70) and the median number of endoscopic sessions was 3 (range 1–9). Conclusions This standardized approach and EVT modification using a tube-in-tube drain, with frequent fistula cleansing, were successful and safe in a wide variety of UGI wall defects.

Neoadjuvant chemoradiotherapy (nCRxt) followed by radical surgery is the optimal treatment for advanced rectal adenocarcinoma. Patients with clinical complete response (cCR) may be followed closely without immediate surgery. Probe-based confocal laser endomicroscopy (pCLE) is a real-time in vivo method that allows acquisition of optical biopsies with 1000 times magnification, evaluating both epithelial and vascular patterns. To evaluate the role of pCLE in the diagnosis of cCR after nCRxt for advanced rectal adenocarcinoma. pCLE was performed in 47 patients with locally advanced rectal adenocarcinoma (T3/T4, or N+) who underwent nCRxt (5-fluorouracil, 5040 cGy). Twenty-seven (57.5%) patients were men, and the mean age was 62.8 years. Thirty-seven had partial response confirmed by pCLE. Ten (21.3%) patients had good endoscopic response and presented small ulcer (n = 5) or residual scar (n = 5). After nCRxt, the essential features to differentiate malignancy from post-radiation alterations at pCLE were the presence of irregular crypts, budding, back-to-back glands, cribriform pattern, increased vessel/crypt ratio, and fluorescein leakage. A scoring system was created considering these epithelial and vascular features, with high accuracy for differentiating patients with complete response from those with residual neoplasia (p < 0.00001). pCLE sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 100%, 71.4%, 95.2%, 100%, and 95.7%, respectively. (1) pCLE evaluation of epithelial and vascular features may improve the diagnosis of cCR and may alter patient management; (2) pCLE might be valuable for identifying patients with advanced rectal cancer who will benefit from watch and wait strategy, avoiding immediate surgical treatment.

Background Studies that describe metastases to the gastrointestinal (GI) tract are restricted to small case series. An increase in the frequency of this condition is expected, so it would be useful to better characterize the endoscopic aspects of metastasis to the GI tract. The aims of this study were to describe the frequency and endoscopic features of the lesions, and to analyze the survival rate after diagnosis of metastasis. Methods This was a retrospective, single-center, observational study, conducted between 2009 and 2017. Patients with metastasis to the GI tract were included. Results 95 patients were included. Melanoma (25.3 %), lung (15.8 %), and breast (14.7 %) were the most frequent primary tumors. The most common endoscopic presentation was a solitary, ulcerated lesion in the gastric body. Conventional biopsy was diagnostic in 98.9 % of the cases. The mean and median survival rates were 13.3 months (95 % confidence interval [CI] 8.2 – 18.3) and 4.7 months (95 %CI 3.7 – 5.6), respectively. Palliative treatment with chemo- and/or radiotherapy after the diagnosis of the metastasis was related to a higher survival rate. Conclusions Melanoma, lung, and breast cancer were the most common primary tumors to metastasize to the GI tract. The endoscopic features could not predict the primary site of the tumor. The finding of metastasis in the GI tract is related to the final stage of the cancer disease but patients who received palliative treatment with chemo- and/or radiotherapy after diagnosis of GI metastasis had higher survival rates.

Background. Management of pharyngoesophageal stenosis (PES) in patients after head and neck cancer (HNC) treatment remains a challenge. It is not uncommon that PES is refractory to dilation sessions. This study aimed at evaluating the efficacy of Mitomycin C (MMC) endoscopic injection for the treatment of refractory pharyngoesophageal stenosis. Patients and methods. This is a prospective study in patients with dysphagia following head and neck cancer treatment, without evidence suggestive of tumor recurrence, and refractory to endoscopic treatment. These patients were submitted to endoscopic dilation of the stenotic segment with thermoplastic bougies, followed by injection of MMC. We repeated the endoscopic sessions every three weeks. Results. From January 2015 to May 2015, we treated 13 patients with PES. Three patients were initially enrolled in the study for refractory stricture. We observed adverse events in all of them, with intense neck pain and ulcer development, justifying the interruption of the trial. Conclusion. The repeated injection in the short interval of MMC in refractory PES is not recommended, because it resulted in serious adverse events.

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.

Aim To investigate the feasibility of a new endoscopic pyloromyotomy technique. Materials and methods Endoscopic pyloromyotomy through a gastric submucosal tunnel was performed in 6 pigs. At the greater curvature, 2 cm proximal to the pylorus, we incised the mucosa and dissected the submucosal tunnel up to the pyloric ring. The pyloric muscular ring was sectioned, and then the gastric mucosal incision was closed with metallic clips. The pigs were then euthanized and necropsies were performed. Results Section of the pyloric ring was successful in all 6 pigs. Small perforations occurred in 2 of the pigs, and there was limited bleeding in 1 pig. Necropsy and histologic evaluation confirmed the pyloric section. Conclusions This technique is feasible, easy to perform, and maybe alternative to pyloroplasty in selected cases. Experimental comparative studies with other techniques still must be performed.

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.