Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients requiring long-term enteral nutrition. Major complications related to the procedure are rare. Buried bumper syndrome is a late major complication, occurring in 0.3-2.4% of patients. Although considered a late complication, it can rarely occur in an acute setting early after the procedure. We present the case of an early buried bumper syndrome, presenting 1 week after PEG tube placement, with local stoma infection associated with an infected cavity within the abdominal wall with feeding content, successfully managed with antibiotic therapy and PEG tube repositioning through the original track.

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Introduction: The use of self-expandable metal stents (SEMS) for the treatment of postoperative leaks of the upper gastrointestinal tract is already established. However, there are discrepancies between the relatively small caliber of the esophageal stents available and the postsurgical luminal size, which may determine an inadequate juxtaposition. As colonic stents have a bigger diameter, they might be more adequate. Additionally, stents with a larger diameter might have a lower risk of migration. Materials and Methods: The aim of this study was to evaluate the efficacy and complications associated with the use of colonic fully covered SEMS (FSEMS) in the treatment of postoperative leaks in critical patients. All patients with postoperative leaks of the upper gastrointestinal tract treated with colonic stents (Hanarostent® CCI) between 2010 and 2013 were retrospectively included. Results: Four patients with postoperative leaks were treated with colonic SEMS. The underlying surgeries were a gastric bypass, an esophagogastrectomy for Boerhaave syndrome, a primary repair of esophagopleural fistula due to Boerhaave syndrome, and an esophagectomy due to esophageal cancer. The leaks were detected on average 17 days after the initial surgery. All patients needed admission to a critical care unit after index surgery. Stent placement was technically feasible in all patients. The median residence time of the stents was 7 weeks, and no complications were verified when they were removed. There were no cases of stent migration. The treatment was successful in all patients, with complete healing of the leaks. Discussion and Conclusions: The placement of colonic FSEMS seems to be successful and safe in the treatment of postoperative leaks of the upper gastrointestinal tract.

Background: Inflammatory bowel disease (IBD) is associated with a variety of extraintestinal manifestations including arterial and venous thromboembolism. Research evidences that IBD patients have about a 2- to 3-fold increase in the risk of venous thromboembolism when compared with the general population. Objectives: We intended to evaluate the coagulation parameters and the prevalence of thromboembolic events (TE) in IBD patients. It was also our aim to investigate the correlation between coagulation parameters and disease phenotype and activity in this population. Methods: This single center prospective observational study was performed between November 2016 and April 2020. The cohort included patients with 18 years of age or older, diagnosed with IBD and followed at a gastroenterology consultation, during a follow-up period of 36 months. Patients were evaluated in terms of IBD type, extent and disease behavior, clinical scores of IBD activity, medication, smoking history, family and personal history of TE, coagulation parameters, fecal calprotectin levels, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), hospitalization due to TE, IBD-related hospitalization or surgery, pregnancy, or diagnosis of malignancy. Results: The study included 149 IBD patients (67 males and 82 females). Coagulation parameters were similar in CD and UC patients and only plasminogen was increased in CD patients [97.4 (17.0) versus 91.6 (13.3), p = 0.035], when comparing with UC patients. The determined values were in the range of the reference values described in literature for the standard population. During the follow-up period, none of the patients experienced a TE that demanded hospitalization. Conclusion: In our study, acquired and inherited risk factors for TE and changes in coagulation parameters did not show to influence prothrombotic predisposition in IBD patients. As such, the clinical relevance of measuring coagulation parameters in this population is questionable. Trial Registry: NCT05162339 (ClinicalTrials.gov ID).

| INTRODUCTIONMerkel cell carcinoma (MCC) is a rare and aggressive primary neuroendocrine tumour of the skin, with a high propensity for local, regional and distant spread. 1 However, distant metastasis of MCC to the pancreas are rarely seen. Endoscopic ultrasound-guided (EUS)-FNA is an effective tool in the evaluation and differential diagnosis of pancreatic mass lesions. 2 Differentiating metastatic pancreatic tumours, especially MCC, from primary pancreatic tumour will influence clinical management and therapeutic strategies. 3The authors describe the case of a MCC metastatic to the pancreas diagnosed by EUS-FNA, avoiding more invasive procedures, with special emphasis on cytological features and immunocytochemistry. | CASE HISTORYA 71-year-old male patient presented with a nodular skin lesion on the left anterior thigh, which was surgically resected and diagnosed to be an MCC with lymphovascular invasion. Fluorine-18 fluorodeoxyglucose positron emission tomography revealed 18 F accumulation at the site of previous resected lesion. A wide excision and sentinel lymph node biopsy was performed, and histopathological examination was negative for residual MCC. Subsequently, the patient underwent adjuvant local radiotherapy. However, 18 months later, he developed recurrence of MCC involving a left inguinal lymph node. Staging computed tomography scan revealed inguinal, iliac and coeliac axis lymphadenopathies and a hypodense pancreatic head lesion. | MATERIAL AN D METHODSComplementary study with abdominal magnetic resonance confirmed the presence of a 3.5 cm pancreatic solid lesion, causing stricture of the common bile duct and distal main pancreatic duct. The patient underwent an EUS, which revealed a hypoechoic, heterogeneous mass with ill-defined borders in the head of the pancreas, with dilatation of both common bile duct and main pancreatic duct, and a 2-cm lymphadenopathy close to the splenic vessels ( Figure 1A,B). EUS-FNA with a 25 gauge needle (wet suction technique) of both the pancreatic mass and the lymphadenopathy was performed. 4 | RESULTS Cytological and cell-block analysis of the pancreas and lymph node showed neoplastic discohesive cells, with granular and vesicular nuclei and mild atypia (Figure 1C,D). Immunohistochemical studies (IHC) performed on the cell block showed that the malignant cells were positive for Cam5.2 (Figure 2A), CK20 (Figure 2B), synaptophysin (Figure 2C) and chromogranin A (Figure 2D), with a cytoplasmatic and perinuclear dot-like staining pattern (Figure 2). Based on these findings, the diagnosis of pancreatic and lymph node metastasis of MCC was made. The patient started on systemic treatment with cysplatin and etoposide, with stable disease after 6 months of follow-up. | DISCUSSIONMerkel cell carcinoma is an aggressive and uncommon skin neuroendocrine tumour, first described by Toker in 1972. 4 MCC is usually diagnosed in elderly and immunocompromised patients, with a notorious propensity to metastasize not only to regional lymph nodes but Juliana Pinho is the article guara...