Background and study aims: Endoscopic mucosal resection (EMR) is used to treat premalignant and malignant digestive tract lesions. This report presents the efficacy and safety of EMR for squamous superficial neoplastic esophageal lesions. Patients and methods: A retrospective cohort study presented data from 51 patients with 54 lesions over an 8-year period, between November 1997 and September 2005. Dysplasias or mucosal (m) T1 carcinomas were treated with repeated EMR until there was complete local remission. Patients with submucosal (sm) T1 carcinomas or more advanced stage were offered surgery or chemoradiotherapy. Results: There was no mortality, perforation, or major hemorrhage, and there were three easily dilated stenoses. Of the patients, 16 had lesions graded as T1sm or more advanced and one patient was found to have normal tissue post EMR. Complete local remission was achieved in 31 of the 34 patients with dysplasia or T1 m cancers (91 %). There was no distant relapse and there was local disease recurrence in eight of the 31 patients (26 %). The 5-year survival rate was 58 %, while the disease specific 5-year survival rate was 95 %. Conclusions: EMR for squamous superficial neoplastic lesions of the esophagus is safe and provides satisfactory survival results.

Background: Liver cirrhosis (LC) is largely associated with diabetes mellitus (DM). More than 80% of patients with LC manifest glucose intolerance and about 30% have type 2 DM. A particular and yet unrecognized entity is hepatogenous diabetes (HD), defined as impaired glucose regulation caused by altered liver function following LC. Numerous studies have shown that DM could negatively influence liver-related outcomes. Aim: We aimed to investigate whether patients with LC and DM are at higher risk for hepatic encephalopathy (HE), variceal hemorrhage (VH), infections and hepatocellular carcinoma (HCC). The impact of DM on liver transplant (LT) outcomes was also addressed. Methods: Literature search was performed in PubMed, Ovid, and Elsevier databases. Population-based observational studies reporting liver outcomes in patients with LC were included. Results: Diabetics are at higher risk for HE, including post-transjugular intrahepatic portosystemic shunt HE. DM also increases the risk of VH and contributes to elevated portal pressure and variceal re-bleeding, while uncontrolled DM is associated with increased risk of bacterial infections. DM also increases the risk of HCC and contributes to adverse LT outcomes. Conclusions: Patients with DM and LC may benefit from close follow-up in order to reduce readmissions and mortality. Due to the heterogeneity of available research, prospective multicenter clinical trials are needed to further validate these findings.

Primary sclerosing cholangitis is a progressive liver disease characterized by chronic inflammation leading to liver fibrosis and cirrhosis. Even though the exact pathogenesis is still unclear, a combination of autoimmune, environmental, and ischemic factors could explain certain aspects of the disease. The most important diagnostic step is cholangiography, which can be obtained either by endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiography (MRCP as the gold standard), or percutaneous transhepatic cholangiography. It shows multifocal short biliary duct strictures leading to the “beaded” aspect. Cholangiocarcinoma and colorectal adenocarcinoma are the most feared complications in patients with Primary sclerosing cholangitis (PSC). Continuous screening consists of annual clinical, biochemical, and ultrasound assessments in asymptomatic patients and annual colonoscopy in patients with PSC and inflammatory bowel disease. In newly diagnosed patients with PSC, colonoscopy is mandatory and, if negative, then, a repeat colonoscopy should be performed in 3–5 years. The lack of efficient curative medical treatment makes invasive treatments such as liver transplant and endoscopy the mainstream for managing PSC and its complications. Until now, even though only ursodeoxycholic acid has shown a moderate clinical, biochemical, and even histological improvement, it has no significant influence on the risk of cholangiocarcinoma, liver transplant need, or death risk and it is no longer recommended in treating early PSC. Further studies are in progress to establish the effect of molecular-targeted therapies in PSC.

We present four patients (# 1 – 4) with esophageal varices due to alcoholic liver cirrhosis diagnosed between June 2006 and July 2007 with early esophageal squamous cell carcinoma (SCC). Cancers were treated by endoscopic mucosal resection (EMR). Patients were male smokers with a mean age of 64 years. Cirrhosis classifications were Child – Pugh A or B (6 or 7 points), and variceal grades were 1 or 2 [ 1 ]. Two patients had a history of esophageal variceal ligation (EVL) for primary (# 4) and secondary (# 2) variceal bleeding prophylaxis, 3 and 5 years before current cancer diagnosis, respectively. Cancers were found during cirrhosis initial evaluation (# 1 and # 3) or esophageal varices surveillance (# 2 and # 4). Lesions were superficial type 0-II [ 2 ], were 2 – 5 cm in length, occupied a third to three-quarters of the esophageal circumference, and were staged uT1N0 by endoscopic ultrasound (EUS). EUS also noticed esophageal varices passing in the submucosa beneath the lesions ([ Fig. 1 ] – [ 3 ]). Before EMR, variceal eradication by EVL (1 – 3 sessions) was carried out in all patients except one (# 1), in whom ligation was preformed at the same time as EMR. All lesions were resected piece-meal using the cap-assisted technique during a single EMR session ([ Fig. 4 ]). There were no complications apart from two immediate bleedings, which were stopped by metallic clips (# 2) and hot forceps (# 4). Coagulation factor V level was 58 % to 92 %, and platelet count was 88 000/cmm to 158 000/cmm. One patient (# 2) died of mesenteric infarction 1 week after EMR, whereas the other three patients were disease free after a median follow-up of 7 months (range 5 – 17). Three similar reports were found in the literature [ 3 ] [ 4 ] [ 5 ], in all cases sclerotherapy or EVL were done before EMR. Here for one patient EVL was done at the same time as EMR. Overall EMR is feasible for early esophageal SCC in liver cirrhosis patients with esophageal varices. Fig. 1 A superficial carcinoma type 0-IIb, 5 cm in length, stretched over three-quarters of the esophageal circumference (patient # 4). Fig. 2 Endoscopic view of the upper part of the lesion after Lugol 2 % chromoscopy. Note the unstained pink/orange neoplastic area (patient #4). Fig. 3 Esophageal varices in the submucosa beneath the lesion as demonstrated by endoscopic ultrasound examination. Lesion staged uT1mN0 (patient #4). Fig. 4 Endoscopic aspect immediately at the end of the endoscopic mucosal resection session (patient # 4). Endoscopy_UCTN_Code_CPL_1AH_2AZ