Endoscopic methods for the detection and treatment of gastric cancer

PURPOSE OF REVIEW

The intent of this review is to describe new advances in endoscopic approaches to surveillance and management of gastric cancer.

RECENT FINDINGS

There are new endoscopic techniques and approaches that have improved the detection of gastric cancer, including narrow band imaging, confocal laser endocytomicroscopy and magnetically controlled capsule endoscopy. This article highlights the role of endoscopic submucosal dissection in the treatment of focal and diffuse gastric dysplasia and early gastric cancer with a discussion of indications, complications and outcomes. We review several recent guidelines addressing the surveillance strategies for individuals at high-risk for developing gastric cancer, such as those with atrophic gastritis and intestinal metaplasia, how gastric dysplasia and early gastric cancer can be endoscopically managed, and recommended surveillance after endoscopic intervention.

SUMMARY

Endoscopic approaches are evolving rapidly that will improve detection of dysplasia and early gastric cancer in high-risk individuals. Surveillance guidelines from various international societies reflect differences in local experience and prevalence of gastric cancer. Endoscopic submucosal dissection is now widely accepted as a first-line approach to early gastric cancers that can be resected en-bloc .

Advances in endoscopic resection techniques of small gastric tumors originating from the muscularis propria

Gastrointestinal stromal tumors are common gastrointestinal tumors typically originating from the muscularis propria layer of the stomach. Small gastric stromal tumors are usually detected incidentally during routine endoscopic examination. Although they may have malignant potentially, controversies remain regarding the need for endoscopic resection of small gastric stromal tumors originating from the muscularis propria. According to the guidelines of the European Society of Medical Oncology, all gastrointestinal stromal tumors >2 cm in size should be resected with endoscopic surveillance recommended for tumors <2 cm. Endoscopic resection including endoscopic mucosal dissection (EMD), endoscopic submucosal dissection (ESD), submucosal tunneling endoscopic resection and snare assisted endoscopic resection. However, EMD and ESD procedures may be accompanied with serious complications including perforation, bleeding, and abdominal infection. Snare-assisted endoscopic resection is an alternative approach and has the advantages of a shorter procedure time and a low rate of perforation or bleeding. This study summarizes the safety and feasibility of a novel snare-assisted endoscopic resection technique and highlights the pros and cons of the different endoscopic approaches currently used for subepithelia small gastric tumors.

Identify metabolism-related genes IDO1, ALDH2, NCOA2, SLC7A5, SLC3A2, LDHB, and HPRT1 as potential prognostic markers and correlate with immune infiltrates in head and neck squamous cell carcinoma

Hypopharyngeal squamous cell carcinoma (HSCC) is a kind of head and neck squamous cell carcinoma (HNSCC) with poor prognosis. Metabolic reprogramming may regulate the tumor microenvironment (TME) by adapting quickly to cellular stress and regulating immune response, but its role in HSCC has not been reported. We used the nCounter^® Metabolic Pathways Panel to investigate metabolic reprogramming, cellular stress, and their relationship in HSCC tissues and adjacent normal tissues. Metabolism-related pathways nucleotide synthesis and glycolysis pathways were significantly upregulated, while amino acid synthesis and fatty acid oxidation pathways were significantly downregulated in HSCC tissues compared to adjacent normal tissues. There is a significant correlation between metabolism-related pathways and cellular stress pathways. Enrichment of immune cell and tumor infiltrating lymphocyte (TIL) analysis showed changes in immune responses between HSCC tissues and adjacent normal tissues. Overall survival analysis showed that upregulated genes CD276, LDHB, SLC3A2, EGFR, SLC7A5, and HPRT1 are potential unfavorable prognostic markers in HNSCC, while downregulated genes EEA1, IDO1, NCOA2, REST, CCL19, and ALDH2 are potential favorable prognostic markers in HNSCC. Moreover, metabolism-related genes IDO1, ALDH2, NCOA2, SLC7A5, SLC3A2, LDHB, and HPRT1 are correlated with immune infiltrates in HNSCC. These results suggest that metabolic reprogramming occurs and correlates with cellular stress and immune response in HSCC, which may help researchers understand mechanisms of metabolic reprogramming and develop effective immunotherapeutic strategies in HNSCC.

Task Autonomy of a Flexible Endoscopic System for Laser-Assisted Surgery

Laser beam steering has been widely studied for the automation of surgery. Currently, flexible instruments for laser surgery are operated entirely by surgeons, which keeps the automation of endoluminal surgery at the initial level. This paper introduces the design of a new workflow that enables the task autonomy of laser-assisted surgery in constrained environments such as the gastrointestinal (GI) tract with a flexible continuum robotic system. Unlike current, laser steering systems driven by piezoelectric require the use of high voltage and are risky. This paper describes a tendon-driven 2 mm diameter flexible manipulator integrated with an endoscope to steer the laser beam. By separating its motion from the total endoscopic system, the designed flexible manipulator can automatically manipulate the laser beam. After the surgical site is searched by the surgeon with a master/slave control, a population-based model-free control method is applied for the flexible manipulator to achieve accurate laser beam steering while overcoming the noise from the visual feedback and disturbances from environment during operation. Simulations and experiments are performed with the system and control methods to demonstrate the proposed framework in a simulated constrained environment.

Therapeutic implications and clinical manifestations of thymoquinone

Thymoquinone (TQ), a natural phytochemical predominantly found in Nigella sativa, has been investigated for its numerous health benefits. TQ showed anti-cancer, anti-oxidant, and anti-inflammatory properties, validated in various disease models. The anti-cancer potential of TQ is goverened by anti-proliferation, cell cycle arrest, apoptosis induction, ROS production, anti-metastasis and anti-angiogenesis, inhibition of cell migration and invasion action. Additionally, TQ exhibited antitumor activity via the modulation of multiple pathways and molecular targets, including Akt, ERK1/2, STAT3, and NF-κB. The present review highlighted the anticancer potential of TQ . We summarize the anti-cancer, anti-oxidant, and anti-inflammatory properties of TQ, focusing on its molecular targets and its promising action in cancer therapy. We further described the molecular mechanisms by which TQ prevents signaling pathways that mediate cancer progression, invasion, and metastasis.

Association Between Family History of Gastric Cancer and the Risk of Gastric Cancer and Adenoma: A Nationwide Population-Based Study

INTRODUCTION

A family history of gastric cancer (GC) is a well-known risk factor for GC. However, the association between family history of GC and the risk of GC and gastric adenoma according to the affected family members is unclear.

METHODS

We analyzed the data of participants aged ≥40 years who underwent national GC screening between 2013 and 2014. Participants with and without a family history of GC among first-degree relatives were matched by age and sex in a 1:4 ratio.

RESULTS

During a median follow-up of 4.9 years, 0.96% and 0.46% of 896,721 participants with a family history of GC and 0.65% and 0.32% of 3,586,884 participants without a family history of GC developed GC and gastric adenoma, respectively. A family history of GC among any first-degree relative was a risk factor for GC (adjusted hazard ratio [HR] 1.48, 95% confidence interval 1.45-1.52) and gastric adenoma (HR 1.44, 95% confidence interval 1.39-1.50). The HRs for GC and gastric adenoma were higher in participants with a family history of GC in parents and siblings (2.26 and 2.19, respectively) than in those with a family history of GC in parents only (1.40 and 1.41, respectively) or siblings only (1.59 and 1.47, respectively). The HRs for GC in participants with vs without a family history of GC were 1.62, 1.55, and 1.42 in the 40-49, 50-59, and ≥60 years' age groups of participants, respectively. Similarly, the HRs for gastric adenoma increased with decreasing age of participants.

DISCUSSION

A family history of GC was a risk factor for both GC and gastric adenoma. The risk of GC and gastric adenoma of the participants was higher when both parents and siblings had GC.

Physical activity and the risk of SARS-CoV-2 infection, severe COVID-19 illness and COVID-19 related mortality in South Korea: a nationwide cohort study

PURPOSE

To determine the potential associations between physical activity and risk of SARS-CoV-2 infection, severe illness from COVID-19 and COVID-19 related death using a nationwide cohort from South Korea.

METHODS

Data regarding 212 768 Korean adults (age ≥20 years), who tested for SARS-CoV-2, from 1 January 2020 to 30 May 2020, were obtained from the National Health Insurance Service of South Korea and further linked with the national general health examination from 1 January 2018 to 31 December 2019 to assess physical activity levels. SARS-CoV-2 positivity, severe COVID-19 illness and COVID-19 related death were the main outcomes. The observation period was between 1 January 2020 and 31 July 2020.

RESULTS

Out of 76 395 participants who completed the general health examination and were tested for SARS-CoV-2, 2295 (3.0%) were positive for SARS-CoV-2, 446 (0.58%) had severe illness from COVID-19 and 45 (0.059%) died from COVID-19. Adults who engaged in both aerobic and muscle strengthening activities according to the 2018 physical activity guidelines had a lower risk of SARS-CoV-2 infection (2.6% vs 3.1%; adjusted relative risk (aRR), 0.85; 95% CI 0.72 to 0.96), severe COVID-19 illness (0.35% vs 0.66%; aRR 0.42; 95% CI 0.19 to 0.91) and COVID-19 related death (0.02% vs 0.08%; aRR 0.24; 95% CI 0.05 to 0.99) than those who engaged in insufficient aerobic and muscle strengthening activities. Furthermore, the recommended range of metabolic equivalent task (MET; 500-1000 MET min/week) was associated with the maximum beneficial effect size for reduced risk of SARS-CoV-2 infection (aRR 0.78; 95% CI 0.66 to 0.92), severe COVID-19 illness (aRR 0.62; 95% CI 0.43 to 0.90) and COVID-19 related death (aRR 0.17; 95% CI 0.07 to 0.98). Similar patterns of association were observed in different sensitivity analyses.

CONCLUSION

Adults who engaged in the recommended levels of physical activity were associated with a decreased likelihood of SARS-CoV-2 infection, severe COVID-19 illness and COVID-19 related death. Our findings suggest that engaging in physical activity has substantial public health value and demonstrates potential benefits to combat COVID-19.

Comparison between Endoscopic Submucosal Dissection and Surgery in Patients with Early Gastric Cancer

Simple Summary

Conventional gastrectomy combined with regional lymph node dissection has been the standard treatment for early gastric cancer (EGC). This retrospective case–control study aimed to compare the clinical outcomes of endoscopic submucosal dissection (ESD) and surgical resection for EGC in China. After propensity score-matching, there were no significant differences between the two groups for OS, RFS, and DSS. Additionally, with similar R0 resection and recurrence rates, the ESD group showed less blood loss, fewer adverse events, lower hospital cost, and a shorter operative time and hospital duration than the surgery group. Therefore, ESD can be a first-line treatment of EGC in addition to surgery.

Abstract

Background: Endoscopic submucosal dissection (ESD) has become a preferred treatment option for early gastric cancer (EGC). This study aimed to compare the clinical outcomes of ESD and surgical resection for EGC. Methods: This was a retrospective case–control study. Patients with a diagnosis of EGC who underwent ESD or surgery in our hospital from 2011 to 2020 were enrolled. We compared the clinical characteristics and treatment outcomes of these two groups according to propensity score-matching. The primary outcome comparison was overall survival (OS). Secondary outcomes were disease-specific survival (DSS), recurrence-free survival (RFS), and treatment-related events. Results: In the matched cohort, the ESD group showed comparable OS, RFS, and DSS with the surgery group. Statistical differences were shown in blood loss and adverse events. Furthermore, the ESD group showed lower hospital cost, as well as a shorter operative time and hospital duration than the surgery group. The R0 resection and recurrence rates were similar between the two groups. In Cox regression analysis, age, tumor size, poor differentiation, and lymphovascular invasion were regarded as independent factors of OS. Conclusions: With sufficient safety and advantages, ESD can be a first-line treatment of EGC. Preoperative evaluation is vital to the appropriate treatment and prognosis.

Application of Endoscopic Ultrasound Combined with Multislice Spiral CT in Diagnosis and Treatment of Patients with Gastrointestinal Eminence Lesions

Objective

To evaluate the application of endoscopic ultrasound (EUS) combined with multislice spiral CT (MSCT) in the diagnosis and treatment of patients with gastric eminence lesions.

Methods

A total of 160 patients with gastric eminence lesions enrolled in our hospital from June 2018 to June 2021 were included and received EUS and MSCT. The results of the two examinations and the postoperative pathological results were compared.

Results

The common pathological types of gastric eminence lesions include polyps and stromal tumors, with the most common sites of lesions in the gastric antrum, followed by the fundus of the stomach and the gastric body. Gastric eminence lesions mostly originate from the mucosal layer and muscularis mucosa, accounting for 83.13% of the total. With pathological results as the gold standard, the detection rate of MSCT was 90.63%, and that of EUS was 78.13%. With the joint diagnosis as a reference, the receiver operating curve (ROC) revealed a higher diagnostic efficiency of MSCT and EUS.

Conclusion

The accuracy of MSCT in the diagnosis of gastric eminence lesions is significantly higher than that of EUS, both of which can offer useful guidance for the choice of endoscopic treatment methods. The combination of MSCT and EUS examination before endoscopic gastroscopy may provide a better treatment efficacy on gastric protruding lesions with high safety.

Endoscopic Resection Versus Surgery in the Treatment of Early Gastric Cancer: A Systematic Review and Meta-Analysis

Background and Aim

Endoscopic resection (ER) is the preferred approach to treat early gastric cancer (EGC) in patients without suspected lymph node involvement and that meet the criteria for ER. Surgery is a more aggressive treatment, but it may be associated with less recurrence and the need for reintervention. Previous meta-analyses comparing ER with surgery for EGC did not incorporate the most recent studies, making accurate conclusions not possible.

Methods

This systematic review and meta-analysis aimed to examine complete resection, length of hospital stay (LOHS), adverse events (AEs), serious AEs, recurrence, 5-year overall survival (OS), and 5-year cancer-specific survival (CSS) in patients with EGC.

Results

A total of 29 cohorts studies involving 20559 patients were included. The ER (n = 7709) group was associated with a lower incidence of AEs (RD = -0.07, 95%CI = -0.1, -0.04, p < 0.0001) and shorter LOHS (95% CI -5.89, -5.32; p < 0,00001) compared to surgery (n = 12850). However, ER was associated with lower complete resection rates (RD = -0.1, 95%CI = -0.15, -0.06; p < 0.00001) and higher rates of recurrence (RD = 0.07, 95%CI = 0.06; p < 0.00001). There were no significant differences between surgery and ER in 5-year OS (RD = -0.01, 95%CI = -0.04, 0.02; p = 0.38), 5-year CSS (RD = 0.01, 95%CI = 0.00, 0.02; p < 0.17), and incidence of serious AEs (RD = -0.03, 95%CI = -0.08, 0.01; p = 0.13).

Conclusions

ER and surgery are safe and effective treatments for EGC. ER provides lower rates of AEs and shorter LOHS compared to surgery. Although ER is associated with lower complete resection rates and a higher risk of recurrence, the OS and CSS were similar between both approaches.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021255328.

Role of functional luminal imaging probe in the management of postmyotomy clinical failure

BACKGROUND AND AIMS

A small percentage of patients with esophageal dysmotility disorders (EDDs) fail to improve or relapse after management by laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM). In this study, we aimed to describe the role of functional luminal imaging probe (FLIP) in identifying patients who might benefit from lower esophageal sphincter (LES)-directed retreatment.

METHODS

This was a retrospective study at 6 tertiary care centers (United States, 4; Europe, 1; Asia, 1) between January 2015 and April 2021 involving patients with prior failed myotomy. The primary outcome was the impact of the use of FLIP on the management of patients with prior failed myotomy.

RESULTS

One hundred twenty-three patients (62 women [50%]; mean age, 53 ± 21.1 years) who underwent LHM (n = 53, 43%) or POEM (n = 70, 57%) for the management of achalasia (n = 98) or other EDDs (n = 25) had clinical failure at a median time of 10.8 months (interquartile range, .8-17.3) postprocedure. Twenty-nine patients had apposing "abnormal" diagnoses in terms of integrated relaxation pressure (IRP) >15 mm Hg on HRM and distensibility index (DI) <2.8 mm²/mm Hg on FLIP, with ultimate change in management noted in 15 patients (10 directed toward conservative management, 5 directed toward LES-directed retreatment). The impact of FLIP on both diagnosis and management was noted in 15 of 29 patients (52%). In the subgroup analysis of 44 patients who underwent LES-directed retreatment, clinical success was highest among patients with both abnormal IRP and DI (21/25 [84%]) versus patients with only abnormal IRP (8/14 [57%]) or only abnormal DI (3/5 [60%], P = .04), with DI at 40-mL distension volume on FLIP identified as an independent predictor of clinical success (odd ratio, 1.51; 95% confidence interval, 1.02-2.1; P = .03).

CONCLUSIONS

The finding of this study further suggests the important role of using FLIP in addition to HRM in evaluating patients with clinical failure postmyotomy.

Differentiating Gastrointestinal Stromal Tumors from Leiomyomas Using a Neural Network Trained on Endoscopic Ultrasonography Images

BACKGROUND

Endoscopic ultrasonography (EUS) is crucial to diagnose and evaluate gastrointestinal mesenchymal tumors (GIMTs). However, EUS-guided biopsy does not always differentiate gastrointestinal stromal tumors (GISTs) from leiomyomas. We evaluated the ability of a convolutional neural network (CNN) to differentiate GISTs from leiomyomas using EUS images. The conventional EUS features of GISTs were also compared with leiomyomas.

PATIENTS AND METHODS

Patients who underwent EUS for evaluation of upper GIMTs between 2010 and 2020 were retrospectively reviewed, and 145 patients (73 women and 72 men; mean age 54.8 ± 13.5 years) with GISTs (n = 109) or leiomyomas (n = 36), confirmed by immunohistochemistry, were included. A total of 978 images collected from 100 patients were used to train and test the CNN system, and 384 images from 45 patients were used for validation. EUS images were also evaluated by an EUS expert for comparison with the CNN system.

RESULTS

The sensitivity, specificity, and accuracy of the CNN system for diagnosis of GIST were 92.0%, 64.3%, and 86.98% for the validation dataset, respectively. In contrast, the sensitivity, specificity, and accuracy of the EUS expert interpretations were 60.5%, 74.3%, and 63.0%, respectively. Concerning EUS features, only higher echogenicity was an independent and significant factor for differentiating GISTs from leiomyomas (p < 0.05).

CONCLUSIONS

The CNN system could diagnose GIMTs with higher accuracy than an EUS expert and could be helpful in differentiating GISTs from leiomyomas. A higher echogenicity may also aid in differentiation.

COVID-19 Morbidity and Severity in Patients With Age-Related Macular Degeneration: A Korean Nationwide Cohort Study

Purpose

To determine the potential association between age-related macular degeneration (AMD), a representative chronic age-related degenerative disease of the retina associated with inflammation and aging, and susceptibility to SARS-CoV-2 infection and severe COVID-19 outcomes.

Design

Nationwide cohort study with propensity-score matching.

Methods

A population-based nationwide cohort in Korea was examined. Data were obtained from the Health Insurance Review & Assessment Service of Korea, including all patients aged ≥40 years who underwent SARS-CoV-2 testing in South Korea between January 1, 2020 and May 15, 2020 (excluding self-referral). The primary outcome was SARS-CoV-2 test positivity and the secondary outcome was severe clinical outcome of COVID-19.

Results

The unmatched cohort consisted of 135,435 patients who were tested for SARS-CoV-2: 4531 patients (3.3%) tested positive for SARS-CoV-2 and 5493 (4.1%) had AMD. After propensity score matching, exudative AMD was associated with an increased likelihood of susceptibility to SARS-CoV-2 infection (adjusted odds ratio [aOR], 1.50; 95% confidence interval [CI], 1.03-2.25), and a considerably greater risk of severe clinical outcomes of COVID-19 (aOR, 2.26; 95% CI, 1.02-5.26), but not any AMD and non-exudative AMD.

Conclusions

In a Korean nationwide cohort, data suggest that clinicians should be aware of the greater risk of susceptibility to severe clinical outcomes of COVID-19 in patients with exudative AMD. These findings provide an improved understanding of the relationship between the pathogenesis of COVID-19 and chronic neurological disorders.

A Comparative Assessment of the Diagnosis of Swallowing Impairment and Gastroesophageal Reflux in Canines and Humans

Swallowing impairment is a highly prevalent and clinically significant problem affecting people and dogs. There are myriad causes of swallowing impairment of which gastroesophageal reflux is the most common in both species. Similarities in anatomy and physiology between humans and canines results in analogous swallowing disorders including cricopharyngeus muscle achalasia, esophageal achalasia, hiatal herniation, and gastroesophageal reflux with secondary esophagitis and esophageal dysmotility. Accordingly, the diagnostic approach to human and canine patients with swallowing impairment is similar. Diagnostic procedures such as swallowing fluoroscopy, high-resolution manometry, pH/impedance monitoring, and endolumenal functional luminal imaging probe can be performed in both species; however, nasofacial conformation, increased esophageal length, and the difficulty of completing several of these procedures in awake dogs are inherent challenges that need to be considered. Human patients can convey their symptoms and respond to verbal cues, whereas veterinarians must rely on clinical histories narrated by pet owners followed by comprehensive physical examination and observation of the animal eating different food consistencies and drinking water. Dogs may also be unwilling to drink or eat in the hospital setting and may be resistant to physical restraint during diagnostic procedures. Despite the species differences and diagnostic challenges, dogs are a natural animal model for many oropharyngeal and esophageal disorders affecting people, which presents a tremendous opportunity for shared learnings. This manuscript reviews the comparative aspects of esophageal anatomy and physiology between humans and canines, summarizes the diagnostic assessment of swallowing impairment in both species, and discusses future considerations for collaborative medicine and translational research.

Esophagogastric junctional neuroendocrine tumor with adenocarcinoma: A case report

BACKGROUND

At present, cases of esophageal neuroendocrine tumors combined with cardia adenocarcinoma are extremely rare worldwide, and there are no clinical reports. Herein, we describe such a case for clinical reference.

CASE SUMMARY

The presence of cardia cancer and esophageal neuroendocrine tumors in a single patient has not yet been reported. The patient in this case underwent prompt endoscopic treatment and additional surgical resection. Pathology revealed the following: The distance between the cardia cancer and the esophageal neuroendocrine tumors was small, approximately 3 mm. Vascular invasion was observed. The esophageal neuroendocrine tumor was determined to be grade G3. According to the treatment guidelines, after the patient received an explanation of their condition, additional surgical procedures were provided in a timely manner. Early detection and early treatment can successfully prolong survival and improve the quality of life of patients.

CONCLUSION

Early detection and early treatment can successfully prolong survival and improve the quality of life of such patients.

Discovery and Identification of Tastants and Taste-Modulating N-Acyl Amino Acid Derivatives in Traditional Korean Fermented Dish Kimchi Using a Sensomics Approach

Sensory-guided fractionation by means of ultrafiltration and gel permeation chromatography followed by high-performance liquid chromatography, synthesis, liquid chromatography-tandem mass spectrometry (LC-MS/MS) quantitation, and taste re-engineering experiments revealed taste-active and taste-enhancing compounds contributing to the umami, mouthful and complex taste profile of the fermented Korean dish, kimchi. Besides basic taste-active compounds, in particular, various N-acylated amino acids deriving from succinic acid and lactic acid imparted taste-modulating properties in food matrices. Taste threshold concentrations were determined to evaluate intrinsic and modulating effects. Quantitation of N-acylated amino acids in kimchi following synthesis revealed the presence of numerous derivatives showing taste-active properties. Sensory evaluation including recombination and partial addition experiments highlighted that both the N-lactoyl- and the N-succinoyl amino acid derivatives contribute to increasing the fullness, volume, and complexity of food matrices, whereas the latter directly contributes to the overall taste of kimchi in natural concentrations.

Practical points that gastrointestinal fellows should know in management of COVID-19

Pandemics obligate providers to transform their clinical practice. An extensive effort has been put to find out feasible approaches for gastrointestinal diseases and also to manage coronavirus disease 2019 (COVID-19) related gastrointestinal conditions. Diarrhea, hepatitis, and pancreatitis can be seen in the COVID-19 course. Endoscopic procedures increase the risk of contamination for medical staff and patients despite precautions, therefore indications should be tailored to balance risks vs benefits. Furthermore, whether the immunosupression in inflammatory bowel diseases, liver transplantation, and autoimmune liver diseases increases COVID-19 related risks and how to modify immunosupression are topics of ongoing debate. This review aims to provide most up to date practical approaches that a gastrointestinal fellow should be aware on the problems and management of gastrointestinal and hepatobiliary diseases during the COVID-19 pandemic.

Impact of rapid on-site evaluation on diagnostic accuracy of EUS-guided fine-needle aspiration of solid pancreatic lesions: experience from a single center

BACKGROUND

The use of ROSE in EUS-FNA pancreatic lesions is still controversial in many centers. In this study, we aimed to demonstrate the contribution of ROSE to the diagnostic accuracy, as well as its assistance to the pathologist/cytopathologist.

METHODS

162 EUS-FNA biopsies were included in the study. EUS-FNA cytology results were reported according to the six-tiered system of Papanicolaou Cytopathology Society and compared to their final diagnosis with histopathology and/or clinical follow-ups regarding malignancy. The diagnostic yield, the difference in diagnostic accuracy, and the contribution of ROSE to providing the pathologist with adequate tissue uptake (number of slides and cell blocks) for further examination were compared in the ROSE and non-ROSE patient groups.

RESULTS

In the non-ROSE group, the diagnostic accuracy according to the final diagnoses was 96% and the sensitivity was 94.44%, specificity 100%, PPV 100%, NPV 87.50%; while diagnostic accuracy was 97.09%, sensitivity 97.47%, specificity 95.83%, PPV 98.77%, NPV 92% in patients with ROSE. There was no significant difference in diagnostic accuracy between those with and without ROSE (p: 0.078). In diagnostic cases, the number of passes, slides and cell blocks were significantly higher in patients with ROSE than those without ROSE (p: 0.003, p: 0.007, p: 0.012, respectively). ROSE was independently associated with diagnostic yield when evaluated by number of passes, slides, cell blocks in regression analysis (p: 0.001, OR: 5.07, confidence interval: 1.89-13.5).

CONCLUSION

ROSE may increase the acquisition of sufficient tissue, but it does not have an advantage in diagnostic accuracy. ROSE may raise the number of slides, which may assist the pathologist for the diagnosis. If the lesion is solid and/or contains a solid component, diagnostic yield is higher in patients where ROSE is available. Therefore, ROSE still maintains its applicability in terms of increasing the diagnostic efficiency and making the final diagnosis.

Clinical characteristics, prognostic factors, and survival trends in esophageal neuroendocrine carcinomas: A population-based study

BACKGROUND

Esophageal neuroendocrine carcinoma (ENEC) is an extremely rare type of malignancy. Clinical data of ENEC are limited to case reports and case series. More information is needed on its clinical feature, management, and prognosis.

METHODS

This study collected information of ENEC patients diagnosed pathologically from 2010 to 2018. Data including demographic information, clinical features, and survival trends were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Statistical analyses were performed with STATA/SE 15.1, SPSS 25.0, and GraphPad Prism 8.

RESULTS

A total of 283 ENEC patients were included in this study. The small-cell and large-cell subtypes of ENEC possess similar clinical features. The lower third of the esophagus (58%) was the most common location of ENEC. At the time of diagnosis, most ENEC patients were AJCC 7th stage IV (48.1%). Metastasis occurred in more than half of the ENEC patients (53.4%), and the most common metastatic site was the liver (37.1%). Compared with poorly differentiated esophageal squamous cell carcinoma (ESCC), another aggressive malignancy of the esophagus sometimes confused with ENEC because of similar histological features, our study showed differences in tumor location and metastatic rate, but similar poor survival rates. Multivariate survival analysis showed that ENEC located at the middle third of esophagus (p = 0.013), "Brain metastasis" (p = 0.019), and "Liver metastasis" (p < 0.001) were independent predictors of worse outcomes. "Surgery" (p = 0.003), and "Chemotherapy" (p < 0.001) were associated with better survival.

CONCLUSION

A significant proportion of patients with newly diagnosed ENEC presented with metastatic disease. Predictors of poor survival included tumor location, brain metastasis, and liver metastasis. ENEC and poorly differentiated ESCC share certain histological features, but differ in tumor location and metastatic rate. Yet, no standard treatment strategy has been established, but surgery and chemotherapy were related to better outcomes.

Comparison of fully coated anti-reflux metal stenting and per-oral endoscopic myotomy in patients with achalasia: a propensity score-matched retrospective study

Background

Achalasia is a rare primary esophageal motility disorder disease. It is reported that the long-term effect of fully coated anti-reflux metal stent (FCARMS) implantation is satisfactory. Operated by a skilled and experienced endoscopist, the effect of per-oral endoscopic myotomy (POEM) treatment is equivalent to that of surgical myotomy. So far, there is still few evidence to prove FCARMS implantation or POEM which is better for achalasia. The choice of treatment for achalasia is still controversial. The aim of this study is to find a more suitable therapy for achalasia by comparing the efficacy of FCARMS implantation and POEM.

Methods

A propensity score (PS) matching (1:2) was used in this retrospective cohort study. Data collected from consecutive patients of Achalasia, receiving FCARMS implantation or POEM therapy at the department of gastroenterology, the Seventh Medical Center of the Chinese People’s Liberation Army General Hospital from May 2007 to May 2018. According to their previous treatment, they are divided into two groups, FCARMS group and POEM group. Clinical efficacy and complications were compared between the two groups.

Results

A total of 166 cases were collected, including 113 cases of FCARMS and 53 cases of POEM. By PS matching, 150 patients were enrolled (100 cases of FCARMS and 50 cases of POEM). By comparison, the FCARMS group has shorter operation time, shorter fasting time and lower hospitalization costs than the POEM group (p < 0.05). Common complications in the FCARMS group are nausea, vomiting, and stent shift. Repetitions of gastroscopy in the FCARMS group was more often, which were 3.8 ± 2.4 (vs 2.1 ± 1.8 of POEM) (p = 0.00 < 0.05) The 6-month remission rates of the FCARMS combination POEM group were 89% and 94%, respectively (p = 0.39), and the 2-year remission rates were 61% and 90%, respectively (p = 0.00).

Conclusions

Stent placement is a cost-effective and safe treatment option for achalasia. The short-term effect (less than 6 months) of FCARMS is similar to that of POEM, the long-term effect (more than 2 years), POEM is better than FCARMS. HRMIIis most suitable for POEM treatment. It indicate that Patients can choose treatment methods according to their own conditions.

Comparison of functional lumen imaging probe and high-resolution manometry to assess response after peroral endoscopic myotomy

BACKGROUND AND AIMS

Outcomes after peroral endoscopic myotomy (POEM) are assessed clinically by the Eckardt score (ES) or objectively by high-resolution manometry (HRM) and functional lumen imaging probe (FLIP). This study compared HRM and FLIP to evaluate clinical response after POEM.

METHODS

This was a single tertiary center retrospective study of consecutive patients who underwent POEM for treatment-naive achalasia and with ≥6 months of follow-up. Baseline and follow-up testing in all patients included ES, HRM, and FLIP of the esophagogastric junction (EGJ). A normal post-POEM (or normalized) EGJ distensibility index (EGJ-DI) >2.8 mm²/mm Hg, maximum EGJ diameter (MxEGJD) ≥14 mm, and integrated relaxation pressure (IRP) <15 mm Hg were compared with a clinical response, defined as ES ≤3.

RESULTS

Eighty-seven patients (58% men, mean age 51 ± 17 years) were included. Overall clinical response by ES, IRP, MxEGJD, and EGJ-DI were 97.7%, 86.2%, 75.9%, and 92.0%, respectively. The sensitivity of a normal IRP (87.1% [95% confidence interval {CI}, 78.0-93.4]) was similar to the sensitivity of a normal MxEGJD (75.3% [95% CI, 64.7-84.0], P = .053) and normal EGJ-DI (91.8% [95% CI, 83.8%-96.6%], P = .39) after POEM to predict clinical response. However, the sensitivity of a normal post-POEM EGJ-DI was superior to a normal post-POEM MxEGJD (P = .001) to predict clinical response. There was no difference in the area under the curve of a normal MxEGJD or EGJ-DI to predict a normal IRP (P = .956) after POEM.

CONCLUSIONS

Normal FLIP metrics ≥6 months after POEM for achalasia show good to excellent sensitivity but are equivalent to a normalized IRP by HRM to predict clinical response by ESs. FLIP may be used as an alternative to HRM to assess lower esophageal sphincter response to POEM in these patients. (Clinical trial registration number: NCT02770859.).

Diagnostic accuracy of endoscopic ultrasound with artificial intelligence for gastrointestinal stromal tumors: A meta-analysis

OBJECTIVES

Gastrointestinal stromal tumors (GISTs) are thought to have a malignant potential. However, utilizing endoscopic ultrasound (EUS) to differentiate GISTs from other types of subepithelial lesions (SELs) remains challenging. Artificial intelligence (AI)-based diagnostic systems for EUS have been reported to have a promising performance, although the results of the previous studies remain controversial. In this meta-analysis, we aimed to assess the diagnostic accuracy of AI-based EUS in distinguishing GISTs from other SELs.

METHODS

A literature search was conducted on MEDLINE and EMBASE databases to identify relevant articles. The sensitivity, specificity, and area under the summary receiver operating characteristic curve (AUROC) of eligible studies were analyzed.

RESULTS

Seven studies were eligible for the final analysis. The combined sensitivity and specificity of AI-based EUS were 0.93 (95% confidence interval [CI] 0.88-0.96) and 0.78 (95% CI 0.67-0.87), respectively. The overall diagnostic odds ratio of AI-based EUS for GISTs was 36.74 (95% CI 17.69-76.30) with an AUROC of 0.94.

CONCLUSIONS

AI-based EUS showed high diagnostic ability and might help better differentiate GISTs from other SELs. More prospective studies on the diagnosis of GISTs using AI-based EUS are warranted in clinical setting.

[Influencing factors for the quality of bowel preparation with polyethylene glycol electrolyte powder combined with diet control before colonoscopy in children]

OBJECTIVES

To investigate the influencing factors for the quality of bowel preparation before colonoscopy in children and the association of the interval from the last administration of laxative to the start of colonoscopy (shortly referred to as waiting time) with the quality of bowel preparation.

METHODS

A retrospective analysis was performed for the children who were admitted to the Department of Gastroenterology, Children's Hospital of Nanjing Medical University, from January to November 2020, and received bowel preparation with polyethylene glycol electrolyte powder combined with diet control before colonoscopy. According to the score of Boston bowel preparation scale, they were divided into two groups: adequate bowel preparation group (n=337) and inadequate bowel preparation group (n=30). Related data were collected from the children in both groups, including general information, possible influencing factors for the quality of bowel preparation, adverse reactions associated with bowel preparation, duration of colonoscopy, and postoperative diagnosis. Univariate and multivariate analyses were used to explore the influencing factors for the quality of bowel preparation.

RESULTS

The univariate analysis showed that age, body weight, and waiting time were associated with inadequate bowel preparation (P<0.05). The multivariate analysis showed that older age (OR=2.155, 95%CI: 1.087-4.273, P=0.028) and longer waiting time (OR=1.559, 95% CI: 1.191-2.041, P=0.001) were independent risk factors for inadequate bowel preparation. The receiver operating characteristic (ROC) curve analysis showed that the cut-off value of waiting time was 5.5 hours in determining whether bowel preparation was adequate or not, with a sensitivity of 90.0%, a specificity of 50.7%, and an area under the ROC curve of 0.708. After grouping based on waiting time, it was found that the incidence rate of inadequate bowel preparation in the ≥5.5 hours group was significantly higher than that in the <5.5 hours group [14.0% (27/193) vs 1.7% (3/174), P<0.001].

CONCLUSIONS

For children who use polyethylene glycol electrolyte powder combined with diet control for bowel preparation, older age is an independent risk factor for inadequate bowel preparation before colonoscopy, which may be associated with an insufficient dose of polyethylene glycol in older children. Longer waiting time is also an independent risk factor for inadequate bowel preparation, and it is recommended that the waiting time should not exceed 5.5 hours.

Efficiency of an endoscopic resection strategy for management of submucosal tumors < 20 mm in the upper gastrointestinal tract

Background and study aims  The histologic diagnosis of submucosal tumors (SMTs) < 20 mm is challenging. Monitoring is the main option offered, but compliance is debatable. Endoscopic resection (ER) of malignant SMTs or those with an uncertain diagnosis is an alternative that has already been reported about and proposed in our center. The aims of this study were to confirm the safety of this resection strategy and to perform long-term follow-up of malignant SMTs after resection. Patients and methods  All patients who underwent ER for SMTs < 2 cm in a single center between 2007 and 2019 were included retrospectively. Patients were classified into two groups according to the need for postresection follow-up: benign SMTs (B-SMTs) and follow-up SMTs (FU-SMTs). Results  One hundred and one patients were included. The mean tumor size was 16.7 mm. In total, 92 of 101 SMTs had an uncertain diagnosis. Macroscopic resection was completed for 95 SMTs (93.1 %), with en bloc resection in 94 (92.1%). The morbidity rate was 3 %, with no mortality. A total of 84 of 101 SMTs (84 %) were B-SMTs and did not need monitoring, and 17 SMTs (19.7 %) were FU-SMTs (8 gastrointestinal stromal tumors, 6 neuroendocrine tumors, and 3 others). No relapse was reported in the FU-SMT group, with a median follow-up duration of 33 months [4-127] (61 months [17-127] for the gastrointestinal stroma tumor group). Conclusions  The study results suggest ER is a potentially reliable and effective strategy for upper gastrointestinal tract SMTs < 20 mm. Although the strategy needs further validation in advanced care units, it could eliminate the need for long-term monitoring, therefore targeting such follow-up efforts to patients with FU-SMTs.

[Not Available]

Objectives and study aims  Recent pilot studies have assessed the feasibility of a novel 1.9-/1.5-μm dual emission endoscopic laser treatment ( _1.9-/1.5-μm DEELT) for endoscopic hemostasis, ablation and resection. In this study, we investigated the safety and efficacy of _1.9-/1.5-μm DEELT in patients with chronic anemia due to gastrointestinal vascular lesions in a real-life multicenter cohort setting.

Patients and methods  Consecutive patients with moderate/severe iron-deficiency anemia undergoing _1.9-/1.5-μm DEELT for upper and lower gastrointestinal bleeding due to vascular lesions were enrolled in three academic referral centers. Safety and successful ablation of vascular lesions were the primary outcomes. Long-term hemoglobin level, blood transfusion requirements, endoscopic severity scores of complex vascular disorders and technical lasing parameters were also assessed. Long-term hemoglobin variations have been further assessed, with repeated measure analysis of variance and univariate analyses.

Results  Fifty patients (median age 74; range 47 to 91 years) with gastric antral vascular ectasia (GAVE) (22), angioectasia (22) and radiation proctopathy (6) underwent 58 _1.9-/1.5-μm DEELT between 2016 and 2020. All procedures were technically feasible leading to successful ablation of the targeted lesion/s, with no incident or adverse event potentially related to the _1.9-/1.5-μm DEELT technique. Within a 6-month follow-up, hemoglobin values significantly rose (+ 1.77 at 1 month and + 1.70 g/dL at 6 months, P  < 0.01), the blood supply requirement decreased (at least one transfusion in 32 versus 13 patients, P  < 0.01), and GAVE lesions showed a clear endoscopic improvement (from 5 points to 1 points, P  < 0.01).

Conclusions  The 1.9-/1.5-μm laser system is a safe and effective endoscopic tool for haemostatic ablation of bleeding vascular lesions within the gastrointestinal tract in tertiary referral centers.

Evaluating patient acceptability and bowel preparation efficacy of sodium picosulfate‐magnesium citrate for colonoscopy

Objective

Methods

Results

Conclusion

Applying High-Resolution Impedance Manometry for Detecting Swallowing Change in Anterior Cervical Spine Surgery Patients

Background

Objectively detecting perioperative swallowing changes is essential for differentiating the reporting of subjective trouble sensations in patients undergoing anterior cervical spine surgery (ACSS). Swallowing indicates the transmission of fluid boluses from the pharynx (velopharynx, oropharynx, and hypopharynx) through the upper esophageal sphincter (UES). Abnormal swallowing can reveal fluid accumulation at the pharynx, which increased the aspiration risk. However, objective evidence is limited. High-resolution impedance manometry (HRIM) was applied for an objective swallowing evaluation for a more detailed analysis. We aimed to elucidate whether HRIM can be used to detect perioperative swallowing changes in patients undergoing ACSS.

Methods

Fourteen patients undergoing elective ACSS underwent HRIM with the Dysphagia Short Questionnaire (DSQ, score: 0–18) preoperatively (PreOP), on postoperative at day 1 (POD1), and postoperative at day seven (POD7). We calculated hypopharyngeal and UES variables, including hypopharyngeal mean peak pressure (PeakP) and UES peak pressure, representing their contractility (normal range of PeakP, 69–280 mmHg; peak pressure, 149–548 mmHg). The velopharynx-to-tongue base contractile (VTI) was also calculated (normal range, 300–700 mmHg.s.cm), indicating contractility. The swallowing risk index (SRI) from HRIM combined with four hypopharyngeal parameters, including PeakP, represents the global swallowing function (normal range, 0–11). A higher SRI value indicated higher aspiration.

Results

SRI was significantly higher on POD1 (10.88 ± 5.69) than PreOP (6.06 ± 3.71) and POD7 (8.99 ± 4.64). In all patients, PeakP was significantly lower on POD1 (61.8 ± 18.0 mmHg) than PreOP (84.9 ±34.7 mmHg) and on POD7 (75.3 ± 23.4 mmHg). The UES peak pressure was significantly lower on POD1 (80.4 ± 30.0 mmHg) than PreOP (112.9 ± 49.3 mmHg) and on POD7 (105.6 ± 59.1 mmHg). Other variables, including VTI, did not change significantly among the three time points. DSQ scores were 1.36, 3.43, and 2.36 at PreOP, POD1, and POD7 respectively.

Conclusions

With similar trends in DSQ and SRI, swallowing was significantly decreased on POD1 because of decreased hypopharyngeal and UES contractility but recovered to the preoperative state on POD7 after ACSS. Applying HRIM is superior to DSQ in detecting mechanisms and monitoring the recovery from swallowing dysfunction.

Clinical Trial Registration

The study was registered at ClinicalTrials.gov (NCT03891940).

ENETS standardized (synoptic) reporting for endoscopy in neuroendocrine tumors

Despite efforts from various endoscopy societies, reporting in the field of endoscopy remains extremely heterogeneous. Harmonisation of clinical practice in endoscopy has been highlighted by application of many clinical practice guidelines and standards pertaining to the endoscopic procedures and reporting are underlined. The aim of the proposed "standardised reporting" is to (1) facilitate recognition of gastrointestinal neuroendocrine neoplasms (NEN) on initial endoscopy, (2) to enable interdisciplinary decision making for treatment by a multidisciplinary team, (3) to provide a basis for a standardised endoscopic follow-up which allows detection of recurrence or progression reliably, (4) to make endoscopic reports on NEN comparable between different units, and (5) to allow research collaboration between NEN centres in terms of consistency of their endoscopic data. The ultimate goal is to improve disease management, patient outcome and reduce the diagnostic burden on the side of the patient by ensuring the highest possible diagnostic accuracy and validity of endoscopic exams and possibly interventions.

The Use of Proton Pump Inhibitors and COVID-19: A Systematic Review and Meta-Analysis

COVID-19 has proved to be a serious, and consequential disease that has affected millions of people globally. Previously, the adverse effects of proton pump inhibitors (PPI) have been observed with increasing the risk of pneumonia and COVID-19. This meta-analysis aims to address the relationship between the use of PPI and the severity of COVID-19 infection. We conducted a systemic literature search from PUBMED, Science Direct, and Cinahl from December 2019 to January 2022. Published and unpublished randomized control trials and cohort studies were included. Review Manager was used for all statistical analyses. In total, 14 studies were included in this systemic review and meta-analysis. Outcomes of interest include: (1) susceptibility of COVID-19 infection and (2) severity of COVID-19 (defined as the composite of poor outcomes: ICU admission, need for oxygen therapy, need for a ventilator, or death), and (3) mortality due to COVID-19. PPI use was marginally associated with a nominal but statistically significant increase in the risk of COVID-19 infection (OR 1.05 [1.01, 1.09]; I2 97%, p = 0.007). PPI use also increased the risk of the composite poor outcome (OR 1.84 [1.71, 1.99]; I2 98%, p < 0.00001) and mortality (OR 1.12 [1.00, 1.25]; I2 84%, p = 0.05) in patients with COVID-19.

Large-Cell Esophageal Neuroendocrine Carcinoma: Report of a Rare Case

Neuroendocrine tumors (NETs) are neoplasms with neuroendocrine characteristics such as secretion of neuropeptides, large secretory vesicles, and a lack of neural structures. Neuroendocrine carcinoma (NEC) of the esophagus is a very rare malignancy. We present the case of a 58-year-old male with a pure large cell NEC of the esophagus.

The Association Between Proton Pump Inhibitors and COVID-19 is Confounded by Hyperglycemia in a Population-Based Study

Background and Aims: There is conflicting evidence regarding the association between proton pump inhibitors (PPI) and the risk of acquisition and severity of acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Aim: To evaluate the association between PPI exposure and infection and development of severe disease in patients infected with SARS-CoV2in a large population-based historical cohort.

Methods: Data were extracted from a health maintenance organization database in Israel that insures over 1,200,000 individuals from across the country. All patients who underwent SARS-CoV-2 testing between March and November 2020 were included. Logistic regression and matched analyses were used to compare patients prescribed and exposed to PPIs to those not prescribed PPIs regarding SARS-CoV-2 positivity. In addition, among SARS-CoV-2 positive patients (n = 44,397) the likelihood of developing severe disease, defined by a composite endpoint of death, ICU admission and prolonged hospitalization, was compared in those exposed and not exposed to PPIs.

Results: Among 255,355 adult patients who underwent SARS-CoV-2 testing by PCR, 44,397 (17.4%) were positive for SARS-CoV-2 and 12,066 (4.7%) patients were prescribed PPIs in the 3 months before testing. In a multivariable logistic regression model controlling for age, gender, smoking status, BMI, diabetes mellitus, hypertension, COPD, history of ischemic heart disease and fasting blood glucose (FBG) levels, no significant association was found between PPIs and SARS-CoV-2 positivity (p = 0.09 aOR 0.94, 95% CI – 0.88–1.01). Among SARS-CoV-2 positive patients, 910 (2%) had a severe infection. Multivariate logistic regression controlling for the abovementioned confounders, showed no such association between PPIs and severe COVID-19 (p = 0.28). Elevated FBG levels were significantly associated with both PPI exposure (p < 0.001) and severe COVID-19 infection (p < 0.001). These results were reinforced by a matched analysis (n = 655 pairs).

Conclusion: PPIs are spuriously associated with severe COVID-19 due to the presence of elevated FBG as a confounder. Our study accounted for the FBG levels of patients and known risk factors for severe COVID-19 infection, which may be the reason for the discrepancy in prior studies. These results may aid in understanding potential confounders when evaluating potential associations of PPIs with other respiratory or viral diseases.

Pneumatic dilation for esophageal achalasia: patient selection and perspectives

Achalasia is an esophageal motility disorder characterized by esophageal aperistalsis and impaired relaxation of the lower esophageal sphincter. Treatment is palliative, aimed at decreasing the lower esophageal sphincter pressure. Pneumatic dilation (PD) is a safe and effective treatment for achalasia. Several other invasive and minimally invasive treatment modalities, such as Laparoscopic Heller Myotomy (LHM) and Peroral Endoscopic Myotomy (POEM), also have a comparable safety and efficacy profile to PD. The current review focuses on the indications, contraindications, techniques, and outcomes of PD in various patient populations and its comparison to LHM and POEM. This review also provides relevant information to help endoscopists identify those patients who will benefit the most from PD.

Prognosis and risk factors of electrocoagulation syndrome after endoscopic submucosal dissection in the colon and rectum. Large cohort study

BACKGROUND

There are few studies on electrocoagulation syndrome after colorectal endoscopic submucosal dissection (ESD). This study aimed to investigate the various risk factors associated with thermal injury and to determine the prognosis of post-colorectal ESD electrocoagulation syndrome (PECS).

METHODS

We conducted a retrospective analysis of the medical records of 395 colorectal neoplasms of 508 patients who were treated with colorectal ESD between January 2013 and December 2019. The incidence, risk factors, and clinical outcomes of colorectal PECS were evaluated and analyzed.

RESULTS

Colorectal PECS occurred in 25 patients (6.3%). The PECS group had a larger lesion size (≥ 40 mm), lesions with fibrosis, longer procedure time, older age, and a larger amount of submucosal injection per square meter than the non-PECS group. In multivariate analysis, lesion with size ≥ 40 mm (odds ratio [OR] 16.941, 95% confidence interval [CI] 3.869-74.178), lesions with fibrosis (OR 7.127, 95% CI 2.541-19.984), old age (OR 1.068, 95% CI 1.010-1.130), and amount of submucosal injection per square meter (OR 1.067, 95% CI 1.015-1.121) were independent risk factors. The PECS group had more fasting days (3.08 vs 1.56 days, P < 0.001), longer hospital stays (7.04 vs 4.09 days, P < 0.001), and higher medical costs (2367 vs 2046, US$, P = 0.004) than the non-PECS group.

CONCLUSION

Lesions with size ≥ 40 mm, lesions with fibrosis, old age, and amount of submucosal injection per square meter were independent risk factors. Therefore, caution should be exercised when performing colorectal ESD in patients with these risk factors.

When to Discharge a Patient After Endoscopy: A Narrative Review

Video endoscopy is an important modality for the diagnosis and treatment of various gastrointestinal diseases. Most endoscopic procedures are performed as outpatient basis, sometimes requiring sedation and deeper levels of anesthesia. Moreover, advances in endoscopic techniques have allowed invasion into the third space and the performance of technically difficult procedures that require the utmost precision. Hence, formulating strategies for the discharge of patients requiring endoscopy is clinically and legally challenging. In this review, we have discussed the various criteria and scores for the discharge of patients who have undergone endoscopic procedures with and without anesthesia.

Colonic Chicken Skin Mucosa Surrounding Colon Polyps Is an Endoscopic Predictive Marker for Colonic Neoplastic Polyps

Background/Aims

Narrow band imaging provides an accurate diagnosis of colonic polyps. However, these diagnostic modalities are not used as standard endoscopic tools in most institutions. This study aims to investigate whether the chicken skin mucosa (CSM) surrounding the colon polyp yields additional information about colorectal polyps, including histological differentiation of neoplastic and non-neoplastic polyps, under conventional white light colonoscopy.

Methods

This study prospectively observed 173 patients who underwent endoscopic polypectomy and reviewed the clinical data and pathologic reports of 313 polyps from a university hospital. Two endoscopists each performed colonoscopy and polypectomy and assessed the CSM. The association between CSM surrounding colorectal polyps and histology was analyzed.

Results

The majority (91.3%) of CSM-positive polyps were neoplastic (sensitivity, 37.90%; specificity, 86.15%; p<0.001). In logistic regression, the neoplastic polyps were associated with positive CSM (adjusted odds ratio [OR], 3.51; 95% confidence interval [CI], 1.45 to 9.25; p=0.007), protruded polyps (adjusted OR, 4.85; 95% CI, 1.65 to 17.23; p=0.008), and neoplastic histology–associated pit pattern (pit III, IV, and V) (adjusted OR, 10.14; 95% CI, 4.85 to 22.12; p=0.000). Furthermore, advanced adenomas were associated with positive CSM (adjusted OR, 5.64; 95% CI, 1.77 to 20.28; p=0.005), protruded polyps (adjusted OR, 3.30; 95% CI, 1.15 to 9.74; p= 0.026), and ≥10 cm polyp size (adjusted OR, 18.56; 95% CI, 3.89 to 147.01; p=0.001).

Conclusions

Neoplastic and advanced polyps were associated with CSM-positive polyps. These findings suggest that CSM is a useful marker in differentiating neoplastic polyps and advanced polyps under conventional white colonoscopy.

Rapidly Extensive Recurrence of Esophageal Neuroendocrine Carcinoma After Complete Pathologic Response to Definitive Chemoradiation

Primary esophageal neuroendocrine carcinoma is a rare, aggressive malignancy lacking evidence-based treatment guidelines. The timing and nature of relapse after successful treatment of locoregional disease are not well characterized. We report a patient lacking risk factors for esophageal cancer who rapidly developed extensive disease recurrence 4 months after achieving complete pathologic response to nonsurgical treatment. Although optimal survival for early stage nonmetastatic disease is achieved by esophagectomy with adjuvant therapy, definitive chemotherapy is also appropriate for late stage nonmetastatic patients. There are presently no protocols for maintenance therapy. We highlight complex treatment considerations for this rare malignancy.

A preferable modality for the differentiation of peripancreatic fluid collections: Endoscopic ultrasound

Background and Objectives:

Peripancreatic fluid collections (PFCs), including walled-off necrosis (WON) and pancreatic pseudocysts (PPCs), are categorized by imaging modalities, including EUS, computed tomography (CT), and magnetic resonance imaging. Our study aimed to evaluate the effectiveness of EUS in differentiating PFCs compared with that of other modalities.

Subjects and Methods:

Data were collected retrospectively from 99 patients at fourteen centers who were recruited to undergo lumen-apposing metal stent placement to treat PFCs.

Results:

PFCs were detected by CT and EUS in 51 WON and 48 PPC patients. The accuracy in differentiating PFCs by EUS was much higher than that of CT (90.9% vs. 50.5%, P < 0.001). The accuracy in identifying WON on EUS was much higher than that on CT (82.4% vs. 13.7%, P < 0.001), while the accuracy in identifying PPC was comparable in these two modalities (89.6% vs. 100%, P > 0.05). WON patients required more times of debridement than PPC patients (P < 0.001).

Conclusion:

EUS can categorize symptomatic PFCs with higher accuracy than CT and is a preferred imaging modality to detect solid necrotic debris.

[Disconnected pancreatic duct syndrome in acute pancreatitis]

The review is devoted to diagnosis and treatment of disconnected pancreatic duct syndrome (DPDS) in patients with acute pancreatitis. Data on terminology, indications and options for endoscopic transluminal interventions are presented in detail. The results of numerous studies evaluating clinical efficacy of various endoscopic and open surgical procedures are analyzed. Available data confirm advisability of staged treatment of DPDS with primary endoscopic drainage of pancreatic fluid accumulations in specialized centers.

Safety and efficacy of endoscopic ultrasound as a diagnostic and therapeutic tool in pediatric patients: a multicenter study

BACKGROUND

Despite the well-established diagnostic and therapeutic applications of endoscopic ultrasound (EUS) in adults, data about its use in children are limited. In this study, we tried to assess the feasibility, safety, and clinical impact of EUS in pediatric patients.

METHODS

Data of pediatric patients (<18 years) referred for EUS over a 3-year period to the endoscopy units of four Egyptian tertiary centers were retrospectively analyzed. Significant impact was defined as a new diagnosis or treatment attributed to the EUS procedure.

RESULTS

Twenty-four diagnostic and five therapeutic EUS procedures were conducted in 29 children with a median age of 9 years. Indications for EUS included assessment of solid pancreatic mass (n = 3), pancreatic cyst (n = 2), suspected chronic pancreatitis (n = 9), pancreatic pseudocyst (PPC) (n = 5), recurrent hypoglycemia (n = 1), bile duct mass (n = 1), subepithelial lesion (esophageal, duodenal or anorectal) (n = 4), mediastinal mass (n = 1), pelvic mass (n = 3), and mass at splenic hilum (n = 1). Therapeutically, five patients underwent cystogastrostomy for symptomatic PPC with 100% technical and clinical success. EUS was able to diagnose 21 out of the other 24 patients. EUS-guided tissue acquisition was performed in 11 patients with definitive histopathological diagnosis in 10 patients (91%). There was no procedure-related major complication, while minor complications occurred in two cases (transient pain in one case, temporary fever, and vomiting in two cases).

CONCLUSION

Standard linear EUS equipment and accessories can be used safely and effectively in selected pediatric patients for diagnostic and therapeutic purposes.

Eosinophilic Esophagitis Patients Are Not at Increased Risk of Severe COVID-19: A Report From a Global Registry

Background

The impact of coronavirus disease 2019 (COVID-19) on eosinophilic esophagitis (EoE) and eosinophilic gastrointestinal diseases (EGIDs) is unknown.

Objective

We aimed to characterize patients with EoE and EGIDs who had COVID-19, assess severity of COVID-19 in the EoE/EGID population, and evaluate for COVID-19-induced EoE/EGID flares.

Methods

We established an online global registry collecting physician entered, deidentified data related to patient demographics, EoE/EGID disease features, comorbidities, and treatments, COVID-19 source of exposure, symptoms, illness severity, hospitalizations, and deaths.

Results

Ninety-four cases were reported between March 2020 and April 2021 (median age, 21 years; range, 1.5-53 years; 73% male). Most had atopy (73%), and 80% had isolated EoE. Before COVID-19, the EoE/EGID activity was reported as clinical remission in 51 (54%) and moderate in 20 (21%). EoE/EGID treatments at the time of COVID-19 included proton pump inhibitors 49 (52%), swallowed/topical steroids 48 (51%), and dietary elimination 34 (36%). COVID-19 symptoms included cough (56%), fever (49%), anosmia (21%), and ageusia (22%). Most patients with COVID-19 had a mild course (70%), with 15% asymptomatic, 12% moderate, and 2% severe. Three patients were hospitalized, and no intensive care unit admissions or deaths were reported. Mean time from first symptoms to resolution in symptomatic patients was 10 days (range, 1-90 days). A single EGID flare was reported during COVID-19.

Conclusions

In a global EoE/EGID registry, relatively few COVID-19 cases have been reported. COVID-19 severity was comparable to the general population. Based on this registry, it does not appear that patients with EoE are at increased risk for severe COVID-19 infection or that COVID-19 leads to EGID flares.

Managing adverse events after endoscopic ultrasound-guided drainage of the biliary tract and pancreatic fluid collections: Narrative review (with video)

Endoscopic ultrasound (EUS)-guided therapeutic procedures have become increasingly common in clinical practice. The development of EUS-guided fine needle aspiration cytology led to the concept of interventional EUS. However, it carries a considerable risk of adverse events (AEs), which occur in approximately 23% of the procedures performed for the drainage of pancreatic fluid collections and 2.5-37.0% of those performed for drainage of the biliary tract. Although the vast majority of AEs occurring after EUS-guided drainage are mild, a deep understanding of such events is necessary for their appropriate management. Because EUS-guided drainage is a novel procedure, there have been few studies of the topic. To our knowledge, this is the first narrative review that focuses on the management and resolution of AEs occurring after EUS-guided drainage of pancreatic fluid collections or the biliary tract. We also include an explanatory video.

Early esophageal neuroendocrine tumor

Esophageal neuroendocrine tumors are rare and often found incidentally on endoscopy. We present a unique case of an esophageal neuroendocrine tumor found in the setting of dysplasia associated with Barrett's esophagus. The tumor was removed endoscopically. This case highlights the incidence, prognosis, and management of esophageal neuroendocrine tumors.

Efficacy of vonoprazan against bleeding from endoscopic submucosal dissection-induced gastric ulcers under antithrombotic medication: A cross-design synthesis of randomized and observational studies

Vonoprazan, a potassium-competitive acid blocker, is expected to be superior to proton pump inhibitors (PPIs) in preventing post-endoscopic submucosal dissection (ESD)-induced gastric bleeding. However, the results of randomized controlled trials (RCTs) and observational studies on the efficacy of vonoprazan have been inconsistent. This study aimed to evaluate the effectiveness of vonoprazan in antithrombotic drug users, a population that has been excluded from RCTs. Treatment effects were assessed using cross-design synthesis, which can be adjusted for differences in study design and patient characteristics. We used data from an RCT in Japan (70 patients in the vonoprazan group and 69 in the PPI group) and an observational study (408 patients in the vonoprazan group and 870 in the PPI group). After matching, among the antithrombotic drug users in the observational study, post-ESD bleeding was noted in 8 out of 86 patients in the vonoprazan group and 18 out of 86 patients in the PPI group. After pooling the data from the RCT and observational study, the risk difference for antithrombotic drug users was -14.6% (95% CI: -22.0 to -7.2). CDS analysis suggested that vonoprazan is more effective than PPIs in preventing post-ESD bleeding among patients administered antithrombotic medications.

Increased Anxiety and Depression Symptoms in Post-Acute Care Patients with Stroke during the COVID-19 Pandemic

This study aimed to explore the quality and stability of post-acute care for patients with stroke, including their functional outcomes, mental health and medical care in Taiwan during the COVID-19 pandemic. In this retrospective case-control study-based on propensity score matching-we assessed 11 patients admitted during the pandemic period (in 2021) and 11 patients admitted during the non-pandemic period (in 2020). Functional outcomes, including the scores of the modified Rankin Scale, Barthel Index, EuroQoL-5 Dimension, Lawton-Brody instrumental activities of daily living, Berg Balance Scale, 5-metre walking speed and 6-min walking distance, were determined. Data on the length of acute care, length of post-acute care, destination after discharge and 14-days readmission were used to evaluate the quality of medical care. The Wilcoxon signed-rank test was used to compare functional performance before and after rehabilitation. The pandemic group showed no significant improvement in the scores of EuroQoL-5 Dimension, a self-reported health status assessment (p = 0.13), with the anxiety or depression dimension showing a negative effect (r = 0.21). Post-acute care programmes can efficiently improve the functional performance of patients with stroke during the COVID-19 pandemic in Taiwan. Mental health should therefore be simultaneously maintained while rehabilitating physical function.

Advances in the Aetiology & Endoscopic Detection and Management of Early Gastric Cancer

Simple Summary

Gastric adenocarcinoma has remained a highly lethal disease. Awareness and recognition of preneoplastic conditions (including gastric atrophy and intestinal metaplasia) using high-resolution white-light endoscopy as well as chromoendoscopy is therefore essential. Helicobacter pylori, a class I carcinogen, remains the main contributor to the development of sporadic distal gastric neoplasia. Management of early gastric neoplasia with endoscopic resections should be in line with standard indications. A multidisciplinary approach to any case of an early gastric neoplasia is imperative. Hereditary forms of gastric cancer require a tailored approach and individua-lized surveillance.

Abstract

The mortality rates of gastric carcinoma remain high, despite the progress in research and development in disease mechanisms and treatment. Therefore, recognition of gastric precancerous lesions and early neoplasia is crucial. Two subtypes of sporadic gastric cancer have been recognized: cardia subtype and non-cardia (distal) subtype, the latter being more frequent and largely associated with infection of Helicobacter pylori, a class I carcinogen. Helicobacter pylori initiates the widely accepted Correa cascade, describing a stepwise progression through precursor lesions from chronic inflammation to gastric atrophy, gastric intestinal metaplasia and neoplasia. Our knowledge on He-licobacter pylori is still limited, and multiple questions in the context of its contribution to the pathogenesis of gastric neoplasia are yet to be answered. Awareness and recognition of gastric atrophy and intestinal metaplasia on high-definition white-light endoscopy, image-enhanced endoscopy and magnification endoscopy, in combination with histology from the biopsies taken accurately according to the protocol, are crucial to guiding the management. Standard indications for endoscopic resections (endoscopic mucosal resection and endoscopic submucosal dissection) of gastric dysplasia and intestinal type of gastric carcinoma have been recommended by multiple societies. Endoscopic evaluation and surveillance should be offered to individuals with an inherited predisposition to gastric carcinoma.

Clinical Effect of Clarithromycin Combined with Tinidazole on Helicobacter pylori-Related Gastritis and Its Influence on COX-2 Expression

Studies have shown that COX-2 expression is upregulated in gastric cancer (GC) as well as in precancerous lesions and in Helicobacter pylori-induced inflammation, suggesting that cyclooxygenase-2 (COX-2) may play an important role in gastric carcinogenesis. We attempted to investigate the role of clarithromycin with tinidazole on Helicobacter pylori-related gastritis from the aspects of clinical effect and COX-2 expression. From January 2016 to January 2019, 130 patients with Helicobacter pylori-related chronic gastritis were collected and grouped into the observation group (OG) and the control group (CG). Altogether, 80 patients in the OG were treated with clarithromycin with tinidazole, while 50 patients in the CG were treated with amoxicillin with metronidazole. Clinical symptom improvement time, content of COX-2 and B cell lymphoma-2 (BCL-2), content of inflammatory factors interleukin-1 (IL-1), IL-4, and C-reactive protein (CRP), expression level of nutritional indicators serum albumin (ALB), realbumin (PA), and transferrin (TF), clearance of Helicobacter pylori, total effective rate, and incidence of adverse reactions were detected. Compared with the CG, the OG had shorter clinical symptom improvement time, lower COX-2 and Bcl-2, lower expression of inflammatory factors IL-1, IL-4, and CRP, higher expression of nutritional indicators ALB, TF, and PA, higher clearance rate of Helicobacter pylori, higher total effective rate, and lower incidence of adverse reactions. Clarithromycin combined with tinidazole can effectively improve the clinical effect of Helicobacter pylori-related gastritis and reduce the expression level of COX-2.

Comparative study for predictability of type 1 gastric variceal rebleeding after endoscopic variceal ligation: High-frequency intraluminal ultrasound study

BACKGROUND

The efficacy of endoscopic ultrasonography for the follow-up of gastric varices treated with endoscopic variceal ligation (EVL) has not been established.

AIM

To evaluate the diagnostic correlation of esophagogastroduodenoscopy (EGD) and high-frequency intraluminal ultrasound (HFIUS) for type 1 gastric varices (GOV1) after EVL and to identify the predictability for rebleeding of EGD and HFIUS.

METHODS

In liver cirrhosis patients with GOV1, we performed endoscopic follow-up using EGD and HFIUS synchronously after EVL for hemorrhage from GOV1. Endoscopic grading and red color signs were analyzed using EGD, and the largest variceal cross-sectional areas were measured using HFIUS. In addition, 1-year follow-up was performed. Variceal rebleeding was defined as the presence of hematemesis, hematochezia, or melena without other evidence of bleeding on endoscopic follow-up.

RESULTS

In 26 patients with GOV1, variceal cross-sectional areas on HFIUS of GOV1 was poorly correlated with EGD grading of GOV1 (r = 0.36). In 17 patients who completed the 1-year follow-up, variceal cross-sectional areas on HFIUS was a good predictor of subsequent rebleeding, whereas EGD grading was not a predictor of subsequent rebleeding.

CONCLUSION

HFIUS measurement is more predictive of GOV1 rebleeding than EGD grading, so HFIUS measurement may be necessary for endoscopic follow-up after EVL in patients with GOV1.