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Background Rectal spacers are used to limit dose to the anterior rectal wall in high dose external beam radiation therapy of the prostate and have been shown to reduce radiation induced toxicity. Here we report the complication rate and toxicity of the implantation procedure in a large cohort of patients who have either received a gel- or balloon-type spacer. Methods In total, 403 patients received rectal spacing, 264 with balloon, 139 with gel. Allocation was non-randomized. Two hundred seventy-six patients were treated with normofractionated regimen, the remaining 125 patients in moderate hypofractionation. Spacer related acute and late rectal toxicity was prospectively assessed by endoscopy using a mucosa scoring system (Vienna Rectoscopy Score) as well as CTCAE V.4. For the balloon subgroup, position and rotation of balloon spacers were additionally correlated to incidence and grade of rectal reactions in a post-hoc analysis of post-implant planning MRIs. Results Overall rectal toxicity was very low with average VRS scores of 0.06 at the day after implantation, 0.10 at the end of RT, 0.31 at 6 months and 0.42 at 12 months follow up. Acute Grade 3 toxicity (rectum perforation and urethral damage) directly related to the implantation procedure occurred in 1.49% ( n  = 6) and was seen exclusively in patients who had received the spacer balloon. Analysis of post implant MR imaging did not identify abnormal or mal-rotated positions of this spacer to be a predictive factors for the occurrence of spacer related G3 toxicities. Conclusions Spacer technology is an effective means to minimize dose to the anterior rectal wall. However, the benefits in terms of dose sparing need to be weighed against the low, but possible risks of complications such as rectum perforation.

Background: Meticulous endoscopic characterization of gastrointestinal neoplasias (GN) is crucial to the clinical outcome. Hereby the indication and type of resection (endoscopically, en-bloc or piece-meal, or surgical resection) are determined. By means of established image-enhanced (IEE) and magnification endoscopy (ME) GN can be characterized in terms of malignancy and invasion depth. In this context, the statistical evidence and accuracy of these diagnostic procedures should be elucidated. Here, we present a systematic review of the literature. Results: 21 Studies could be found which met the inclusion criteria. In clinical prospective trials and meta-analyses, the diagnostic accuracy of >90% for characterization of malignant neoplasms could be documented, if ME with IEE was used in squamous cell esophageal cancer, stomach, or colonic GN. Conclusions: Currently, by means of optical diagnosis, today’s gastrointestinal endoscopy is capable of determining the histological subtype, exact lateral spread, and depth of invasion of a lesion. The prerequisites for this are an exact knowledge of the anatomical structures, the endoscopic classifications based on them, and a systematic learning process, which can be supported by training courses. More prospective clinical studies are required, especially in the field of Barrett’s esophagus and duodenal neoplasia.

Pancreatic trauma in children is rare; therefore, both scientific knowledge and clinical experience regarding its management are limited. Abdominal sonography and subsequent computed tomography (CT) imaging are the diagnostic mainstay after severe abdominal trauma in many pediatric trauma centers. However, the diagnosis of pancreatic injury is missed on the initial imaging in approximately one third of cases, with even higher numbers in young children. While conservative treatment is preferred in low-grade injuries, surgical interventions may be indicated in more severe injuries. We present a case series including four patients with high-grade pancreatic injury. Two patients were treated surgically with open laparotomy and primary suture of the head of the pancreas and pancreatico-enterostomy, one patient underwent endoscopic stenting of the pancreatic duct and one received conservative management including observation and secondary endoscopic treatment. We want to emphasize the fact that using a minimally invasive approach can be a feasible option in high-grade pancreatic injury in selected cases. Therefore, we advocate the necessity of fully staffed and equipped high-level pediatric trauma centers.

Endoscopic submucosal dissection (ESD) is an effective treatment of early esophageal adenocarcinomas (EACs). The decision of ESD over esophagectomy is based on clinical evaluation of tumor depth and invasion. On a molecular level, tumor invasion is strongly associated with epithelial-to-mesenchymal transition (EMT). Here, we investigated whether localized ESD-resected and surgically resected EAC samples displayed different expression profiles of EMT protein and microRNA markers and whether these different expression profiles were able to retrospectively discriminate localized and surgically resected samples. By doing this, we aimed to evaluate whether preoperative measurement of EMT marker expression might support the decision regarding ESD over surgery. The results showed that ESD-resected samples displayed an epithelial expression profile, i.e., high expression of epithelial protein markers, whereas surgically resected samples displayed high expression of mesenchymal markers. In addition, the anti-EMT microRNA-205 was significantly more expressed in ESD-resected samples, whereas we found no significant differences in the expression levels of microRNA-200 family members. Furthermore, in our retrospective approach, we have demonstrated that measurement of selected EMT markers and microRNA-205 has significant discrimination power to distinguish ESD-resected and surgically resected samples. We suggest that the assessment of EMT status of EAC samples on a molecular level may support clinical evaluation regarding the applicability of ESD.

BackgroundIn recent years, flexible endoscopic therapy of Zenker’s diverticulum seems to become the standard approach. The aim of this study was to assess the safety, efficacy and short-term outcome of flexible endoscopic diverticulotomy of Zenker’s diverticulum with a pulsed Holmium laser (PHL).Patients and methodsAll patients treated with endoscopic laser-diverticulotomy using a PHL between February 2013 and November 2021 at the University Hospital Salzburg were extracted from our prospectively maintained endoscopic database. Demographic data, size of Zenker’s diverticulum, procedure duration, complications, short-term outcome and rate of recurrence were evaluated.ResultsIn the study period, 45 procedures in 36 patients were performed. Mean depth of the Zenker diverticulum was 21 mm (10–60 mm), mean procedure time was 31 min (15–60 min), intraprocedural adverse events occurred in 2 out of 45 patients (5%) which were both managed endoscopically, post-procedural stenosis occurred in 1 patient (2%). In the follow-up examinations (mean follow-up after 6.4 months), 27 out of 36 patients (75%) were symptom-free, 6 patients (17%) reported an improvement of dysphagia. 3 patients (9%) suffered from persistent dysphagia. After initial symptom relief, a recurrent diverticulum occurred in 5 patients. Endoscopic re-intervention with PHL was done in these cases.ConclusionsFlexible endoscopic treatment of primary and recurrent Zenker’s diverticulum using a PHL is a promising, safe and effective treatment with, in our opinion, technical advantages in comparison to the CO2 laser. Further controlled prospective trials are needed.

PurposeProstate cancer (PCA) is highly heterogeneous in terms of its oncologic outcome. We therefore aimed to tailor radiation treatment to the risk status by using three different hypofractionated radiation regimen differing in applied dose, use of rectum spacer, inclusion of pelvic lymph nodes (pLN) and use of androgen deprivation therapy (ADT). Here we report on acute toxicity, quality of life (QOL) and oncologic outcome at a median follow-up of 12 months.MethodsA total of 221 consecutive PCA patients received hypofractionated intensity-modulated radiotherapy (IMRT). Low-risk (LR) patients were planned to receive 60 Gy in 20 fractions (EQD2α/β1.5 = 77.1 Gy), intermediate-risk (IR) patients 63 Gy in 21 fractions (EQD2α/β1.5 = 81 Gy), and high-risk (HR) patients 67.5 Gy in 25 fractions (EQD2α/β1.5 = 81 Gy) to the prostate and 50 Gy in 25 fractions to the pLN. Acute rectal toxicity was assessed by endoscopy. In addition, toxicity was scored using CTC-AE 4.0 and IPSS score, while QOL was assessed using QLQ-PR25 questionnaires.ResultsAcute CTC reactions were slightly higher in the HR regimen but reverted to baseline at 3 months. GI G2 toxicity was 4%, 0% and 12% for the LR, IR and HR regimen. Compared to IR patients, the increase in toxicity in HR patients was statistically significant (p = 0.002) and mainly caused by a higher incidence of diarrhea presumably due to pelvic EBRT. QOL scores of all domains were worse for the HR regimen (not significant).ConclusionRisk-adapted moderate hypofractionation is associated with low GI/GU toxicity. Given the higher rate of pelvic metastases in HR patients, slightly higher transient acute reactions should be outweighed by possible oncological benefits.

Background: The treatment of locally advanced rectal cancer (LARC) has steadily progressed over the past four decades, with recent focus shifting towards total neoadjuvant therapy (TNT). This survey aims to elucidate the perceived surgical challenges faced by Austrian colorectal surgeons performing total mesorectal excision (TME), focusing on the increased complexity and surgical difficulty introduced by intensified treatment regimens. Methods: A comprehensive survey was conducted among Austrian colorectal surgeons to explore various aspects of managing and performing TME following TNT. The survey included questions on the general management of LARC within their institutions and utilized a five-point Likert scale to assess the respondents’ perceptions and experiences regarding surgical precision and post-operative morbidity associated with TNT. Results: A total of 31 surgeons (54% response rate) completed the survey. Regarding multidisciplinary therapy preferences, 56% of respondents preferred conventional neoadjuvant therapy regimens, with 32% favoring chemoradiotherapy and 24% opting for short-course radiotherapy, while 31% chose TNT. The majority of respondents (65%) reported quality differences in tissue dissection during TME following TNT, with 57% experiencing difficulties in identifying tissue planes and 47% noting increased tissue fragility. Increased bleeding was reported by 32% of respondents. In cases of regrowth after a watch-and-wait approach, 64% observed quality changes in tissue dissection, and 47% noted tissue fragility. Conclusions: The survey results indicate that TNT impairs surgical precision due to changes in tissue quality and challenges in identifying surgical planes. Given the critical importance of surgical precision in achieving low local recurrence rates in mid-to-low LARC, these challenges could significantly impact patient outcomes. Further prospective studies are required to elucidate the extent of these effects.

PurposeThis study was conducted to investigate the potential predictive value of tumor budding for neoadjuvant chemoradiotherapy response in locally advanced rectal cancer.Patients and methodsSurgical specimens of 128 ypUICC (Union for International Cancer Control) stage 0–III mid-to-low rectal cancer patients were identified from a prospectively maintained colorectal cancer database and classified into two groups using the 10 high-power field average method: none/mild tumor budding (BD-0) and moderate/severe tumor budding (BD-1). Overall survival, relapse-free survival (RFS), and recurrence estimates were calculated using the Kaplan–Meier method and compared with the log-rank test. For RFS, a multivariable Cox’s proportional hazards regression analysis was performed.ResultsNo (n = 20) or mild (n = 27) tumor budding (BD-0) was identified in 47 (37%) and moderate (n = 52) or severe (n = 29) tumor budding (BD-1) in 81 (63%) surgical specimens. Positive tumor budding (BD-1) was associated with significantly reduced T‑level downstaging (P < 0.001) and tumor regression (P < 0.001). After a median follow-up time of 7 years (range 2.9–146.7 months), BD-0 patients had more favorable 5‑year RFS (90 vs. 71%, P = 0.02) and distant recurrence (2 vs. 12%, P = 0.03) estimates. Multivariable analyses confirmed BD-1 as a negative predictive parameter for RFS (hazard ratio = 3.44, 95% confidence interval 1.23–9.63, P = 0.018).ConclusionsOur data confirm tumor budding as a strong prognostic factor and its potential predictive value for neoadjuvant chemoradiotherapy response in locally advanced rectal cancer patients. This provides the opportunity to modify and individualize neoadjuvant therapy regimens for non-responders.

Background/Objectives: Endoscopic submucosal dissection (ESD) is a state-of-the-art en bloc resection for early gastro-intestinal cancers and precursors developed and validated in Japan. Western expertise with this complex technique remains limited. Tutored training might be optimal for patients and ESD learning. We established ESD tutoring courses led by experienced Japanese experts to provide (i) optimal long-term curative outcomes and low complication rates for patients and (ii) hands-on training on difficult lesions for European endoscopists under direct expert supervision. Methods: Prospective data from 2011 to 2015 (follow-up to 12/2024) were analyzed. A total of 118 neoplasms (50% HGIEN and cancer) in 101 patients (median age 68 [37–91] years; 38% with significant comorbidities) were treated with expert or tutored ESD. Japanese experts performed 28 ESDs, while 22 trained beginners conducted 90 supervised procedures on difficult lesions during 5 live and 20 tutoring events (1–4 days each). Results: Analysis of the complete data showed curative and en bloc resection rates of 88% and 95%, respectively, with no recurrence after R0 resections during a median follow-up of 9.8 [1.5–14.9] years. Long-term survival remained recurrence-free after endoscopic resection of 3 recurrent adenomas (at R1/Rx) and curative surgery/2nd ESD for 5 non-curative ESDs. Adverse events occurred in 9.3% without emergency surgery or 30-day mortality. Comparing expert-only vs. tutored ESD procedures, beginners correctly applied curative ESD indications in 94% of 118 neoplasms. Experts resected larger lesions (22 cm2) at a rate of 9.3 cm2/h in 121 min. Tutored beginners achieved a 75% [25–100] self-completion rate on 33% smaller lesions in 112 min. Conclusions: ESD tutoring courses led by Japanese experts ensure excellent patient outcomes and standardized procedural training. This model may foster professional ESD performance across European referral centers.