Endoscopic submucosal dissection (ESD) requires special skills and a long procedure time for a quality-controlled procedure. A universal training system remains to be established. Hands-on courses in animal models before advancing to the human colon appear to be essential, especially in Europe. The learning curve is a prerequisite in ESD, in order to improve technical outcomes and decrease the rate of procedural adverse events. In the experimental research center of ELPEN Pharmaceuticals, 18 European endoscopists, inexperienced at ESD, performed gastric ESDs in porcine models. The course lasted two days and was conducted under the supervision of experts. A total of 72 of 76 ESDs were completed en bloc (94.7%). The procedural time and cutting speed differed significantly between the first and second day: 48±4.4 vs. 43±4.8 min (P=0.0045), and 1.38±0.20 vs. 1.63±0.23 cm2/min (P=0.0033), respectively. The complications were not significantly different between the two groups: five (13.88%) vs. four (11%) episodes of bleeding (P>0.05). The perforation rate was similar, at two episodes per day (5.55%). We documented an acceptable rate of en bloc resections and complications. ESD demands a new level of endoscopic skills in Europe. A formal sequential training program, using porcine models, may benefit countries with a low volume of cases.

Background and aim: We conducted an equivalence trial of quadruple non-bismuth “concomitant” and “hybrid” regimens for H. pylori eradication in a high clarithromycin resistance area. Methods: There were 321 treatment-naïve H. pylori-positive individuals in this multicenter clinical trial randomized to either the hybrid (esomeprazole 40 mg/bid, amoxicillin 1 g/bid for 7 days, then 7 days esomeprazole 40 mg/bid, amoxicillin 1 g/bid, clarithromycin 500 mg/bid, and metronidazole 500 mg/bid) or the concomitant regimen (all medications given concurrently bid for 10 days). Eradication was tested using histology and/or a 13C-urea breath test. Results: The concomitant regimen had 161 patients (90F/71M, mean 54.5 years, 26.7% smokers, 30.4% ulcer) and the hybrid regimen had 160 (80F/80M, mean 52.8 years, 35.6% smokers, 31.2% ulcer). The regimens were equivalent, by intention to treat 85% and 81.8%, (p = 0.5), and per protocol analysis 91.8% and 87.8%, (p = 0.3), respectively. The eradication rate by resistance, between concomitant and hybrid regimens, was in susceptible strains (97% and 97%, p = 0.6), clarithromycin single-resistant strains (86% and 90%, p = 0.9), metronidazole single-resistant strains (96% and 81%, p = 0.1), and dual-resistant strains (70% and 53%, p = 0.5). The side effects were comparable, except for diarrhea being more frequent in the concomitant regimen. Conclusions: A 14-day hybrid regimen is equivalent to a 10-day concomitant regimen currently used in high clarithromycin and metronidazole resistance areas. Both regimens are well tolerated and safe.

The endoscopic management of benign short post-anastomotic ileocolonic stricture (PAICS) that is refractory to primary and secondary treatment modalities remains challenging. The lumen-apposing metal stent (LAMS) is a novel device recently developed for therapeutic gastrointestinal endoscopy. LAMSs have demonstrated significantly better results with regard to stent migration than fully covered self-expandable metal stents (FCSEMSs). This article presents six cases of symptomatic PAICS successfully treated with a LAMS and a review of the relevant literature. We report a life-saving technique not previously documented and the use of technology to improve patient outcomes. The six patients (median age, 75 years) suffered from vomiting, constipation and recurrent abdominal pain, with symptoms starting 23-25 wk post-surgery. The median stricture length was 1.83 cm. All six patients underwent successful and uneventful bi-flanged metal stent (BFMS)-LAMS placement for benign PAICS. All patients remained asymptomatic during the three months of stent indwelling and up to a median of 7 mo after stent removal. According to the literature, the application of LAMS for PAICS is associated with a < 10% risk of migration and a < 5% risk of bleeding. Conversely, FCSEMS has a high migration rate (15%-50%). The evolving role of interventional endoscopy and the availability of LAMSs provide patients with minimally invasive treatment options, allowing them to avoid more invasive surgical inter ventions. The BFMS (NAGI stent) is longer and larger than the prototype AXIOS-LAMS, which should be considered in the management of short ileocolonic post-anastomotic strictures longer than 10 mm and shorter than 30 mm.

Lipomas are rare, nonepithelial, benign tumors representing 5 % of all gastrointestinal tumors. They are the third most common benign mass in the colon. Colonic lipomas are sessile and infrequently pedunculated. The development of symptoms correlates with their size, with 75 % of lipomas with a diameter of > 4 cm being symptomatic [1] [2]. Treatment of large ileocolic lipomas with colonoscopic resection, however, is undefined. Pedunculated lipomas up to 11 cm have been removed via snare polypectomy without perforation [3]. Surgery is preferable when giant lipomas (diameter > 4 cm) are complicated by intussusception, bowel obstruction, are sessile, or the serosa/muscularis propria extends into the stalk of the pedunculated lipoma [4]. A 71-year-old woman was referred to our institution for removal of a large (diameter 6 cm) pedunculated lipoma, histologically documented ([Fig. 1]) and arising from the ileocecal valve ([Fig. 2]). She had experienced intermittent, crampy, right-abdominal pain for 5 months. During colonoscopy, intussusception of the lipoma into the terminal ileum or into the cecum was observed ([Fig. 3]). On endoscopic ultrasonography, the lipoma appeared as a hyperechoic lesion with regular borders in the three layers, without extension of the muscularis propria into the pedicle. The stalk had a diameter of 1.5 cm and length of 2.5 cm. On consideration of our findings, together with suggestions from other authors in the literature [2] [3] [4], we decided to proceed with endoscopic resection of the lipoma. Successful snare polypectomy was performed after endolooping the base of the stalk ([Fig. 4], [Video 1]). Post-polypectomy bleeding (oozing) was stopped by clipping ([Fig. 5]). Using only endoscopic ligation of the lipoma (loop-and-let-go) was not selected because of the possible transformation into liposarcoma. Therefore, the entire tumor was sent for histopathologic examination [5]. The patient was discharged from the hospital the next day in good condition. New histopathologic examination of the tumor revealed fat cells proliferating in the submucosal layer. Video 1 Endoscopic resection of a giant pedunculated lipoma. To conclude, symptomatic, large, benign, pedunculated, ileocolic lipomas, without extension of serosa/muscularis propria into the stalk, could be safely resected endoscopically. Endoscopy_UCTN_Code_TTT_1AQ_2AD Article published online: 09 March 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

A 86-year-old woman was referred for recurrent bleeding secondary to a 4-cm cT2N0 cancer of the distal rectum ([Fig. 1]). Tumor staging was negative for metastasis. She had a history of severe aortic stenosis and atrial fibrillation under anticoagulants, making her a poor candidate for surgical treatment by total mesorectal excision. After a multidisciplinary approach and informed patient consent, we performed a palliative endoscopic resection of the tumor by means of endoscopic submucosal techniques under propofol sedation [(Video 1]). Video 1 Salvage endoscopic wide-field full-thickness resection of T2 rectal cancer with endoscopic submucosal dissection instruments, without defect closure. After circumferential muscular incision ([Fig. 2], [Fig. 3]), the specimen was progressively dissected from the perirectal fat using a square tip endoscopic submucosal dissection (ESD) knife (Square-Knife, Endoaccess, Garbsen, Germany) in spray coagulation mode (Effect 3.0, VIO3, ERBE, Tübingen, Germany). Large perirectal vessels were coagulated with hot biopsy forceps. No major bleeding was encountered. At the end of the procedure, which lasted 80 minutes, the hemi-circumferential wall defect was left open ([Fig. 4], [Fig. 5]), since this approach has been demonstrated to be safe after surgical local resections [1]. The patient received broad spectrum antibiotics and a liquid diet for 1 week. She was hospitalized for 2 days and had an uneventful recovery. Endoscopy 1 month later confirmed complete wound healing and the patient received local radiotherapy. At 2 years of endoscopic and radiologic follow-up, she remains asymptomatic without evidence of local recurrence or distal metastasis on imaging and endoscopy In conclusion, we presented an endoscopic salvage resection of a symptomatic T2 rectal cancer in a patient who was a poor candidate for transabdominal surgery. Local excision is an acceptable treatment for T1N0 early rectal cancer, however there is limited data for high-risk T1 and T2 tumors [2] [3]. In a meta-analysis, pT1/pT2 rectal cancers treated with local excision and adjuvant (chemo)radiotherapy were associated with a 14 % local recurrence rate and 9 % distant recurrence [4]. Although this approach cannot be generalized, we demonstrated the feasibility of endoscopic excision in highly selected cases. Endoscopy_UCTN_Code_TTT_1AQ_2AD Article published online: 07 June 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany