B Bordacahar

Sessile serrated adenoma: from identification to resection.

Until the past two decades, almost all colorectal polyps were divided into two main groups: hyperplastic polyps and adenomas. Sessile serrated adenomas presented endoscopic, pathological and molecular profiles distinct from others polyps. Previously under-diagnosed, physicians now identified sessile serrated adenomas. The serrated neoplastic pathway is accounting for up to one-third of all sporadic colorectal cancers and sessile serrated adenomas have been identified as the main precursor lesions in serrated carcinogenesis. By analogy with the adenoma-adenocarcinoma sequence, the sessile serrated adenomas-adenocarcinoma sequence, has been identified. The development of endoscopic resection techniques permits the consideration of a non-surgical approach as the first option regardless of the size of the lesion. Sessile serrated adenoma warrants the watchfulness of physicians and requires an optimal quality of the colonoscopy procedure, a thorough evaluation of the lesion, an adequate endoscopic resection and follow-up colonoscopies in accordance with sessile serrated adenomas guidelines. We herein present a review on sessile serrated adenomas focusing on their pathological specificities, epidemiology, treatment modalities and follow-up.

Submucosal tunneling endoscopic septum division for Zenker’s diverticulum: a reproducible procedure for endoscopists who perform peroral endoscopic myotomy

Zenker’s diverticulum is a rare disease occurring in less than 0.5% of the global population. Currently, the diverticuloscope-assisted diverticulotomy represents the traditional procedure, the diverticuloscope enabling better exposure of the muscular fibers. Although effective and safer than surgery, this technique could be complicated by perforation, which is reported in as many as 6.5 % of patients [1]. Recently, Li et al. reported a novel technique called the submucosal tunneling endoscopic septum division (STESD) [2], inspired by the peroral endoscopic myotomy (POEM) technique [3]. The theoretical advantage is to completely dissect the muscular septum without mucosal opening. This video case reports the second successful treatment of Zenker’s diverticulum using this new procedure. A 72-year-old woman underwent upper endoscopy for dysphagia, revealing a Zenker’s diverticulum 20cm from the incisors (▶Fig. 1), which was confirmed by esophagogram (▶Fig. 2). We performed the diverticulotomy using the STESD technique (▶Video 1) and a gastroscope (Fujinon, Tokyo, Japan) with cap. Submucosal incision was performed after submucosal injection, 3 cm above the diverticular septum. A tunnel was made using a 1.5mm FlushKnife (Erbe Elektromedizin, Tübingen, Germany) between the muscular layers and the mucosa until the muscular septum was reached, and then continued along both sides of the septum, to create a large endoscopic window. Thereafter, the diverticular septum was completely dissected (with spread coagulation) along its entire length. Finally, after hemostasis, the mucosal incision was closed by four clips. Intravenous antibiotics were continued for 2 days postoperatively, and the patient was discharged at Day 3. Symptoms had totally resolved 15 days later. In summary, STESD is a reproducible technique that is easily accessible to enE-Videos

Mirizzi’s syndrome in Roux-en-Y bypass patient successfully treated with cholangioscopically-guided laser lithotripsy via percutaneous gastrostomy

Obesity and bariatric surgery are major risk factors in gallstone disease. In patients with a past history of Roux-en-Y gastric bypass, Mirizzi’s syndrome is a challenging endoscopic situation because of the modified anatomy. Here we report the first case of a patient with a Roux-en-Y gastric bypass treated by intracorporeal lithotripsy with a digital single-operator cholangioscope following an endoscopic retrograde cholangiopancreatography (ERCP) using a percutaneous gastrostomy access.

DUODENAL TUMOR RISK IN LYNCH SYNDROME

BACKGROUND AND AIMS Lynch syndrome (LS) is associated with an increased risk of small bowel tumors but routine screening is not recommended in international guidelines. The aim of our study was to determinate the prevalence of duodenal tumors in a French cohort of LS patients. METHODS Patients carrying a germline pathogenic variant in a MMR gene, supported by our local network, in which at least one upper endoscopy had been performed, were included. We registered the occurrence of duodenal lesions in those patients. RESULTS 154 LS patients were identified including respectively 85 MSH2 and 41 MLH1 mutated patients respectively. Seven out of 154 (4.5%) had at least one duodenal lesion. Median age at diagnosis was 58 years (range: 49-73). The twelve lesions locations were: descending duodenum (n = 7), genu inferius (n = 2), duodenal bulb (n = 1), ampulla (n = 1), fourth duodenum (n = 1). Three lesions were invasive adenocarcinomas. The incidence rate of duodenal lesions in patients with MSH2 or MLH1 pathogenic variants was respectively 7.1% (6 out of 85) and 2.4% (1 out of 41) emphasizing a trend toward increased risk of developing duodenal lesion in MSH2 mutated patients: OR: 5.17, IC95% (0.8-60.07), p = 0.1307. CONCLUSION Regarding this high prevalence rate, especially in MSH2 patients, regular duodenal screening during upper endoscopy should be considered in routine in LS patients.

Intraductal radiofrequency ablation of an intraductal papillary mucinous neoplasia of the main pancreatic duct

An 82-year-old man was referred for exploration and treatment of a stenosis of the main pancreatic duct that was found incidentally during a computed tomography (CT) scan. He reported no symptoms. Endoscopic ultrasonography (EUS) showed an 8-mm intraductal nodule in the pancreatic isthmus (▶Fig. 1), with upstream dilatation of the main pancreatic duct, a pancreas divisum, and a gaping minor papilla. Endoscopic retrograde cholangiopancreatography (ERCP)-guided brush cytology and EUS-guided biopsy found an intraductal papillary mucinous neoplasia (IPMN) with dysplasia (▶Fig. 2). Sphincterotomy was performed and a 7-Fr plastic stent was inserted through the minor papilla. Pancreatic resection was deemed inadvisable given the patient’s age and comorbid conditions. After multidisciplinary team discussion, intraductal radiofrequency ablation (RFA) was offered 2 months later (▶Video1). A Habib endo-HPB RFA probe (EMcision Ltd, London, UK) was inserted into the dorsal pancreatic duct over a guidewire (▶Fig. 3) with the two electrodes straddling the mural nodule. RFA was applied for 60 seconds (power 10W, effect 8) ▶ Fig. 1 Endoscopic ultrasonography view of a tissue nodule protruding into the main pancreatic duct. ▶ Fig. 2 Endoscopic retrograde cholangiopancreatography view of a small pancreatic duct stricture with upstream pancreatic duct dilatation.