58-year-old female, with a medical history of stage IIB Hodgkin lymphoma in remission for over 5 years post-chemoradiation, and treated invasive breast and renal carcinomas, was incidentally diagnosed with a cardiac gastric polyp on a follow-up computed tomography (CT). Upper endoscopy and endoscopic ultrasound (EUS) revealed a 50mm ulcerated polypoid subepithelial lesion (Figure 1) originating from a small stalk in the muscularis propria (MP). Biopsies and fine needle biopsy were inconclusive but without epithelial neoplastic tissue. Subsequent staging showed no lymph nodes or distant metastasis. Given the high morbidity associated with surgery – total gastrectomy –, the tumor's small insertion in the MP, the patient's lack of lymph node involvement or distant metastasis, and their preference for a less invasive approach, endoscopic submucosal dissection (ESD) was chosen as the optimal treatment option. En bloc ESD was performed without technical difficulties, revealing the lesion’s superficial origin in the MP (Fig. 2), which eliminated the need for perforation and subsequent defect closure. However, because of its dimension and shape, the specimen was fragmented during retrieval. Histological analysis confirmed gastric leiomyosarcoma with non-evaluable margins (Figure 3). Following multidisciplinary discussion, surveillance was recommended. At 12-months follow-up, the patient remains with no signs of recurrence at CT and endoscopic evaluation. Primary leiomyosarcoma of the stomach is an extremely rare neoplasm[1], that can arise from the muscularis propria (more frequently) or the muscularis mucosa, with the latter presenting as intraluminal type and the former as infiltrative[2]. Ionizing radiation and Epstein-Barr virus have been suggested as associated risk factors[2]. Imaging diagnosis is often achieved using CT scans and EUS, which are valuable tools in evaluating these cases, specially the latter one as it enables the sampling of deeper tumor tissues with ultrasound-guided fine-needle aspiration. However, as demonstrated in our case, distinguishing leiomyosarcomas from other gastric tumors with these methods can be challenging. Endoscopic biopsies are also frequently ineffective due to the submucosal origin of the lesion. Smooth muscle tumors, including leiomyoma and leiomyosarcoma, typically show positivity for smooth muscle markers such as actin, desmin, and h-caldesmon, while they are generally negative for c-kit (CD-117) and CD-34[3]. Surgical resection remains the standard treatment for smooth muscle tumors, as it allows for complete removal of the neoplasm and provides the best chance for curative outcomes[4]. However, there are limited reports in the literature exploring the use of ESD to treat these tumors[5]. ESD offers the advantage of en bloc resection, which is particularly beneficial for managing localized disease. In this case, although the specimen fragmented during retrieval—a potential disadvantage of this technique—the lesion itself was resected en bloc during the ESD, which is the most critical factor for achieving optimal clinical outcomes. While fragmentation may limit certain aspects of histological examination, the complete en bloc resection during ESD remains the primary determinant of clinical success. This approach can potentially minimize morbidity and mortality associated with more invasive surgical procedures, making ESD a viable alternative in selected cases in which the tumor is confined and surgical risks are high.

Background: Dysphagia is a prevalent condition which may severely impact the patient’s quality of life. However, there are still lacking standardized therapeutic options for esophageal motility disorders. Summary: Dysphagia is defined as a subjective sensation of difficulty swallowing which can result from oropharyngeal or esophageal etiologies. Regarding esophageal dysphagia, after excluding structural causes and esophageal mucosal lesions, high-resolution manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. HRM has not only improved the sensitivity for detecting achalasia but has also expanded our understanding of spastic and hypomotility disorders of the esophageal body. The Chicago Classification v4.0 uses a hierarchical approach and provides a standardized diagnosis of esophageal motility disorders, allowing a tailored therapeutic approach. Dysphagia is often a long-term health problem that broadly impacts health and well-being and leads to physical and psychosocial disability, namely, malnutrition and aspiration pneumonia, as well as social isolation, depression, and anxiety. Apart from achalasia, most esophageal motility disorders tend to have a benign long-term course with symptoms of dysphagia and noncardiac chest pain that can improve significantly over time. Patient-reported outcomes (PROs) are self-assessment tools that capture the patients’ illness experience and help providers better understand symptoms from the patients’ perspective. Therefore, PROs have a critical role in providing patient-centered care. Key Messages: Motility disorders should be ruled out in the presence of nonobstructive esophageal dysphagia, and treatment options should be considered according to the severity of symptoms reported by the patient.

Endoscopic submucosal dissection (ESD) in colorectal lesions is demanding, and a significant rate of non-curative procedures is expected. We aimed to assess the rate of residual lesion after a piecemeal ESD resection, or after an en bloc resection but with positive horizontal margins (local-risk resection—LocRR), for colorectal benign neoplasia. A retrospective multicenter analysis of consecutive colorectal ESDs was performed. Patients with LocRR ESDs for the treatment of benign colorectal lesions with at least one follow-up endoscopy were included. A cohort of en bloc resected lesions, with negative margins, was used as the control. A total of 2255 colorectal ESDs were reviewed; 352 of the ESDs were “non-curative”. Among them, 209 were LocRR: 133 high-grade dysplasia and 76 low-grade dysplasia. Ten cases were excluded due to missing data. A total of 146 consecutive curative resections were retrieved for comparison. Compared to the “curative group”, LocRRs were observed in lengthier procedures, with larger lesions, and in non-granular LSTs. Recurrence was higher in the LocRR group (16/199, 8% vs. 1/146, 0.7%; p = 0.002). However, statistical significance was lost when considering only en bloc resections with positive horizontal margins (p = 0.068). In conclusion, a higher rate of residual lesion was found after a piecemeal ESD resection, but not after an en bloc resection with positive horizontal margins.

Introduction: Dysphagia is a prevalent condition (20%), and occurs more frequently in women and in older people. It negatively impacts innumerous aspects of patient’s personal and professional lives. Patient-reported outcomes allow patients to directly quantify their experience regarding dysphagia and evaluate its true impact on quality of life. Among the scales available, Patient-Reported Outcomes Measurement Information System Gastrointestinal (PROMIS GI) Disrupted Swallowing stands out because it is a robust instrument that can be applied regardless of the type and etiology of dysphagia. The aim of this study was to translate, culturally adapt and validate PROMIS GI Disrupted Swallowing scale for the Portuguese-speaking population.Material and Methods: Firstly, the seven items of the scale were translated and transculturally reviewed following the systematic method proposed by the Functional Assessment of Chronic Illness Therapy (FACIT). Afterwards, the pre-test version of the questionnaire was administered to a convenience sample (n = 6) for semantic evaluation, with the aim of detection and subsequent correction of possible problems in the translation. The final translated and certified version of the scale was administered to 200 voluntary adult participants (n = 123 healthy; n = 77 dysphagia) in Portugal, for evaluation of reliability and validity.Results: The Portuguese version of PROMIS GI Disrupted Swallowing presented acceptable internal consistency (coefficient of Cronbach’s α of 0.919) and adequate test-retest reliability (intraclass correlation coefficient of 0.941). The translated version of the scale revealed a strong correlation with both Eckardt score (p < 0.001; ρ = 0.782) and the quality-of-life questionnaire EuroQol-5D (p < 0.001; ρ = -0.551), demonstrating evidence of convergent validity.Conclusion: The Portuguese version of PROMIS GI Disrupted Swallowing scale presented conceptual, semantic, cultural and measurement equivalence relatively to the original items. The results attained demonstrated that the translation of this scale to Portuguese is reliable and valid for use both in clinical practice and for research purposes.

Introduction: Endoscopic submucosal dissection (ESD) of lesions with severe submucosal fibrosis has been associated with worse outcomes, such as lower curative resection rate and higher incidence of adverse events. This study aims to investigate its true impact on rectal ESD performed in the West and to assess predictive factors of severe fibrosis. Methods: We conducted a retrospective study including all rectal ESDs performed at our tertiary center from January 2013 to January 2021. Lesions were grouped as nonsevere fibrosis or severe fibrosis. ESD outcomes, predictors of severe fibrosis, and the learning curve were evaluated. Results: ESD was performed in 195 lesions, 45 with severe fibrosis. Three resections were interrupted (one due to severe fibrosis). The presence of severe fibrosis was related to a significantly lower resection speed (16.93 mm2/min vs. 24.66 mm2/min, p = 0.007), en bloc (86.4% vs. 96.6%, p = 0.019), R0 (61.4% vs. 79.7%, p = 0.013), and curative (54.5% vs. 78.4%, p = 0.003) resection rates and a higher rate of hybrid ESD required to complete resection (13.6% vs. 2.0%, p = 0.005). No significant difference was noted regarding adverse events rate (18.2% vs. 8.1%, p = 0.09). Male sex, ulcerative colitis, pelvic radiotherapy, a lesion on the anastomotic site, previous manipulation, and deep submucosal invasion were independent predictors for severe fibrosis. En bloc resection rate improved during time (60.0% vs. 94.1%, p = 0.018). Conclusions: Severe submucosal fibrosis is an important factor related to noncurative resections and challenging rectal ESD. Factors predicting its severity are extremely important and could allow more experienced endoscopists to be assigned to more difficult cases, allowing safer procedures.

Biliary injury secondary to trauma is frequently associated with long-term complications. Liver transplantation is rarely indicated but might be the best therapeutic option in severe or intractable cases. We report the case of a 19-year-old male referred for liver transplantation due to biliary injury after abdominal trauma. A Roux-en-Y hepaticojejunostomy was initially performed without immediate complications. Anastomotic stricture developed requiring several trials of biliary dilatation and stenting through a percutaneous approach. The presence of liver cirrhosis and the intractability of this complication culminated in the decision of liver transplantation. The authors present clinical course, complications and interventional procedures that were used in a judicious step-up approach.