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Background: Current guidelines recommend performing esophagectomy after endoscopic resection for early esophageal cancer when the risk of lymph node metastasis or residual cancer is found to be significant and endoscopic treatment is therefore noncurative. Our aim was to assess the safety and oncological outcomes of esophagogastric resection in this specific clinical setting. Patients and methods: A retrospective review from 2012 to 2018 was performed at four tertiary referral centers. All patients had a noncurative endoscopic resection of a clinical T1 esophageal cancer, followed by esophagectomy. Outcome measures were the rates of T0N0 specimens, overall survival, disease-free and cancer-specific survival, postoperative morbidity and mortality. Results: A total of 30 patients (13 with squamous cell carcinoma and 17 with adenocarcinoma) were included. The reasons for noncurative endoscopic resection were: positive vertical margins (n = 12), squamous cell carcinoma with muscularis mucosae or submucosal layer invasion (n = 3 and 9), adenocarcinoma with deep submucosal invasion (n = 11), poorly differentiated tumor (n = 6) and lymphovascular invasion (n = 6). Overall, 63% of the esophagi were T0N0: most residual lesions were T1a metachronous lesions, and four (13%) patients had advanced pT status (n = 3) or lymph node metastases (n = 2). Overall survival, disease-free survival and cancer-specific survival were 83%, 75%, and 90% respectively. A total of 43% of patients had severe postoperative complications, and postoperative mortality was 7%. Conclusion: In this cohort, esophagectomy allowed the resection of residual advanced cancer or lymph node metastases in 13% of cases, at the cost of 43% severe morbidity and 7% mortality. Therefore, the possibility of close follow up needs to be balanced with a highly morbid surgical management in these patients.

Background Pancreatitis is the most feared complication of endoscopic papillectomy (EP). Prevention by pancreatic duct stenting following EP has been advocated but not proven by a randomized trial. The purpose of the present retrospective review is to compare a period of systematic stenting with the period before in which stents were placed selectively. Methods A total of 107 patients undergoing EP from February 1999 to December 2009 were retrospectively reviewed. After an initial period with selective stenting (dilated duct, previous pancreatitis) between 1999 and 2002 ( n  = 24, group 1), stents were placed routinely after EP unless pancreas divisum was diagnosed (2002–2009; n  = 83, group 2) to reduce postpapillectomy acute pancreatitis (PAP). PAP rates defined by Consensus Criteria were compared in the two periods. Results Five patients in group 1 were selected to receive a pancreatic stent (21 %); in group 2 stenting was successful in 75 of 78 patients (success rate 96 %) without pancreas divisum ( n  = 5). Overall, PAP occurred in 11 % of patients. PAP rate was significantly reduced after introduction of systematic pancreatic stenting (5 vs 25 %; p  = 0.01) and occurred less often in stented than in nonstented patients: (5 % (4/80) vs 27 % (6/22), p  = 0.0019). PAP also occurred in one of five patients with pancreas divisum. Selective stenting of patients also was an independent risk factor for PAP (OR 13, p  = 0.001) in a multivariate analysis. Conclusions Attempts at systematic stenting after EP pancreatic stenting appears to prevent PAP. Results should be corroborated by a randomized trial.

Epiploic appendages are small, fat-filled, serosa-covered structures located on the antimesenteric surface of the colon. These structures are usually 0.5- to 5-cm long and 1- to 2-cm thick, and hang into the peritoneal cavity. Although the total number of epiploic appendages on the colon is about 100, the size and number increase in the lower abdominal quadrants (57% are located on the sigmoid colon and 26% on the ileocecum).1,2 Epiploic appendages have no known function. Vascularization of an appendage is provided by two arteries and one vein. In the case of torsion, the venous component is affected first with subsequent inflammation. Primary epiploic appendagitis caused by torsion is distinguished from secondary appendagitis, which can occur in patients with pericolic inflammatory fluid, as in colitis.2 Other proposed causes are lymphoid hyperplasia or bacterial invasion secondary to a deep abdominal infection (e.g., diverticulitis, appendicitis or cholecystitis) making the coexistence of these pathologies possible.1,3 The prevalence is unknown because most cases are self-limited.4 It has a peak incidence in the fourth and fifth decades but can occur at any age, with a slightly higher frequency in middle-aged men.1

Hartnup disease; biliverdin; pyocyanin pigment from pseudomonas urinary tract infection; and ingested substances (including cimetidine, methylene blue, amitriptyline, indometacin, and food colouring).1-3 Propofol is a commonly used intravenous anaesthetic; therefore, it is worth remembering this benign and reversible-yet alarming in appearance-side-effect to avoid distress among patients and clinicians or unnecessary expensive analysis.

INTRODUCTION:The adoption of colorectal endoscopic submucosal dissection (ESD) is still limited in the West. A recent randomized trial showed that ESD is more effective and only slightly riskier than piecemeal endoscopic mucosal resection; reproducibility outside expert centers was questioned. We evaluated the results according to the annual case volume in a multicentric prospective cohort.METHODS:Between September 2019 and September 2022, colorectal ESD was consecutively performed at 13 participating centers classified as low volume (LV), middle volume (MV), and high volume (HV). The main procedural outcomes were assessed. Multivariate and propensity score matching analyses were performed.RESULTS:Three thousand seven hundred seventy ESDs were included. HV centers treated larger and more often colonic lesions than MV and LV centers. En bloc, R0, and curative resection rates were 95.2%, 87.4%, and 83.2%, respectively, and were higher at HV than at MV and LV centers. HV centers also achieved a faster dissection speed. Delayed bleeding and surgery for complications rates were 5.4% and 0.8%, respectively, without significant differences. The perforation rate (overall: 9%) was higher at MV than at LV and HV centers. Lesion characteristics, but not volume center, were independently associated with both R1 resection and perforation. However, after propensity score matching, R0 rates were significantly higher at HV than at LV centers, and perforation rates were significantly higher at MV than at HV centers.DISCUSSION:Colorectal ESD can be successfully implemented in the West, even in nonexpert centers. However, difficult lesions must still be referred to experts.

BackgroundFor large non-pedunculated rectal polyps, en bloc resection via endoscopic submucosal dissection (ESD) is typically recommended due to presumed higher risk of submucosal invasive cancer (SMIC) compared with the colon; however, data on cancer risk by location remain controversial.ObjectiveUsing the French ESD registry, we compared SMIC rates in large non-pedunculated colorectal polyps in the rectum versus colon. Procedural outcomes were also compared.DesignFrom September 2019 to September 2022, all large non-pedunculated polyps resected by ESD in 13 centres were included. Oncological and procedural outcomes were analysed using propensity score matching (PSM) and inverse probability weighting, accounting for relevant influencing factors. A subgroup analysis was performed on cases from the three largest centres, where such polyps were exclusively treated with ESD.ResultsAmong 3770 lesions, 3310 were analysed. Rectal lesions were larger (56.0 (40; 75) mm vs 47.0 (37; 62) mm), more often granular (80.0% vs 59.4%) and mixed nodular (54.0% vs 32.5%) (p<0.001). After PSM, submucosal cancer rates were not significantly different between rectal and colonic lesions of similar size and morphology (9.8% vs 8.9%, p=0.52). En bloc (97.7% vs 97.3%, p=0.757) and R0 resection rates (89.7% vs 89.5%, p=0.937) were also comparable. Perforation (5.5% vs 7.9%, p=0.057) and surgery for complications (0.1% vs 1.1%, p=0.051) showed a non-significant trend towards higher rates in colonic procedures. Subgroup analysis from the three centres exclusively performing ESD for large non-pedunculated polyps confirmed these findings.ConclusionIn our multicentre registry, large non-pedunculated polyps do not show a higher prevalence of SMIC in the rectum compared with colon, when adjusted for relevant factors such as size and morphology. Therefore, risk features, rather than location, should guide the choice of resection technique. Technical outcomes were comparable between rectal and colonic ESD, with a trend for higher complication rates in the colon.Trial registration numberNCT04592003.

The aim of this study was to assess rheumatoid arthritis (RA) synovitis with positron emission tomography (PET) and( 18)F-fluorodeoxyglucose ((18)F-FDG) in comparison with dynamic magnetic resonance imaging (MRI) and ultrasonography (US). Sixteen knees in 16 patients with active RA were assessed with PET, MRI and US at baseline and 4 weeks after initiation of anti-TNF-alpha treatment. All studies were performed within 4 days. Visual and semi-quantitative (standardised uptake value, SUV) analyses of the synovial uptake of FDG were performed. The dynamic enhancement rate and the static enhancement were measured after i.v. gadolinium injection and the synovial thickness was measured in the medial, lateral patellar and suprapatellar recesses by US. Serum levels of C-reactive protein (CRP) and metalloproteinase-3 (MMP-3) were also measured. PET was positive in 69% of knees while MRI and US were positive in 69% and 75%. Positivity on one imaging technique was strongly associated with positivity on the other two. PET-positive knees exhibited significantly higher SUVs, higher MRI parameters and greater synovial thickness compared with PET-negative knees, whereas serum CRP and MMP-3 levels were not significantly different. SUVs were significantly correlated with all MRI parameters, with synovial thickness and with serum CRP and MMP-3 levels at baseline. Changes in SUVs after 4 weeks were also correlated with changes in MRI parameters and in serum CRP and MMP-3 levels, but not with changes in synovial thickness. (18)F-FDG PET is a unique imaging technique for assessing the metabolic activity of synovitis. The PET findings are correlated with MRI and US assessments of the pannus in RA, as well as with the classical serum parameter of inflammation, CRP, and the synovium-derived parameter, serum MMP-3. Further studies are warranted to establish the place of metabolic imaging of synovitis in RA.

Purpose: The aim of this study was to assess rheumatoid arthritis (RA) synovitis with positron emission tomography (PET) and F-18-fluorodeoxyglucose (F-18-FDG) in comparison with dynamic magnetic resonance imaging (MRI) and ultrasonography (US). Methods: Sixteen knees in 16 patients with active RA were assessed with PET, MRI and US at baseline and 4 weeks after initiation of anti-TNF-alpha treatment. All studies were performed within 4 days. Visual and semi-quantitative (standardised uptake value, SUV) analyses of the synovial uptake of FDG were performed. The dynamic enhancement rate and the static enhancement were measured after i.v. gadolinium injection and the synovial thickness was measured in the medial, lateral patellar and suprapatellar recesses by US. Serum levels of C-reactive protein (CRP) and metalloproteinase-3 (MMP-3) were also measured. Results: PET was positive in 69% of knees while MRI and US were positive in 69% and 75%. Positivity on one imaging technique was strongly associated with positivity on the other two. PET-positive knees exhibited significantly higher SUVs, higher MRI parameters and greater synovial thickness compared with PET-negative knees, whereas serum CRP and MMP-3 levels were not significantly different. SUVs were significantly correlated with all MRI parameters, with synovial thickness and with serum CRP and MMP-3 levels at baseline. Changes in SUVs after 4 weeks were also correlated with changes in MRI parameters and in serum CRP and MMP-3 levels, but not with changes in synovial thickness. Conclusion: F-18-FDG PET is a unique imaging technique for assessing the metabolic activity of synovitis. The PET findings are correlated with MRI and US assessments of the pannus in RA, as well as with the classical serum parameter of inflammation, CRP, and the synovium-derived parameter, serum MMP-3. Further studies are warranted to establish the place of metabolic imaging of synovitis in RA.

Pernicious anemia (PA) was considered an exclusive complication of primary autoimmune gastritis. The hypothesis that PA may be triggered by Helicobacter Pilory (HP) is still controversial. A 34 years old Turkish woman complains of asthenia in 2002. Familiar antecedents include type 1 diabetes (anti GAD+) and Hashimoto thyroiditis. She is diagnosed with Hashimoto hypothyroidism (TSH 7,3 mUI/L, TPO 100 mUI/L) and treated with 125 pg of LThyroxin. Iron microcytic anemia work up reveals an HP associated gastritis. Endoscopic biopsies confirmed antrum and corporeal lymphocytic infiltration with a pattern of atrophic gastritis. Helicobacter eradication and intramuscular iron are prescribed. During thyroid follow-up, surgery is decided in 2010, because of a large 2 cm cold left thyroid nodule. Left nodule histology is benign but a 7 mm right papillary thyroid cancer is found. In 2011, she presents with a B12 deficiency megaloblastic anemia (1/160 anti-parietal cell antibodies, intrinsic factor antibodies: negative). Gastric biopsies reveal duodenitis, antrum and gastric atrophy, intestinal metaplasia and the presence of several colonies of HP. After a second round treatment and intramuscular B12, gastroscopy confirms HP eradication, with antrum and corpus atrophic gastritis in 2012. Since 2013 up to know, gastric biopsies show the same pattern of antrum and corpus atrophic gastritis, with further enterochromaffin cell hyperplasia development. This case report challenges the classical definition of PA. HelicobacterPylori may also be involved in the pathogenesis of PA, through molecular mimicry and anti-parietal cell antibodies production. Microcytic anemia may be present earlier than megaloblastic anemia, because of the lack of proper acidity for iron absorption. Whereas primary autoimmune gastritis spares the antrum, HP infection does not. B12 malabsorption can occur associated with gastric atrophy and in the absence of intrinsic factor antibodies. This case supports the hypothesis that PA can be triggered by HP in immunologically predisposed patients. Patients with PA have significantly higher risk for developing endocrine autoimmunity, carcinoid and gastric tumors: a lifelong follow up is warranted.