The role of type II esophageal microbiota in achalasia: Activation of macrophages and degeneration of myenteric neurons.

OBJECTIVE: The gut microbiota plays a critical role in the appropriate development and maintenance of the enteric nervous system (ENS). Esophageal achalasia (EA) is a rare motility disorder characterized by the selective degeneration of inhibitory neurons in the esophageal myenteric plexus. This study aimed to evaluate the composition of the esophageal microbiota in achalasia and explore the potential microbial mechanisms involved in its pathogenesis. DESIGN: The lower esophageal mucosal microbiota was analyzed in patients with achalasia and control participants using 16 S rRNA sequencing. The association between the esophageal microbiota and achalasia was validated by inducing esophageal dysbiosis in C57BL/10 J and C57BL/10ScNJ (TLR4KO) mice via chronic exposure to ampicillin sodium in their drinking water. RESULTS: The esophageal microbiota in EA patients had lower diversity and a predominance of Gram-negative bacteria (Type II microbiota) compared to that in the healthy controls. Additionally, the relative abundance of Rhodobacter decreased significantly in patients with achalasia, which correlated with an enrichment of lipopolysaccharide (LPS) biosynthesis based on the COG database. Antibiotic-treated mice showed an esophageal microbiota characterized by increased abundance of Gram-negative bacteria (Type II microbiome), decreased abundance of Rhodobacter, and enriched LPS biosynthesis. Compared to the control and TLR4KO mice, the antibiotic-treated wild-type mice had higher LES resting pressure, increased LES contraction rate after carbachol stimulation, and decreased relaxation response to L-arginine. Moreover, the number of myenteric neurons decreased, while the number of lamina propria macrophages (LpMs) increased after antibiotic exposure. Furthermore, the TLR4-MYD88-NF-κB pathway was up-regulated, and the production of TNF-α, IL-1ß, and IL-6 increased in the antibiotic-treated mice. CONCLUSIONS: Patients with achalasia exhibit esophageal dysbiosis, which may induce aberrant esophageal motility.

A single-cell transcriptional landscape of immune cells shows disease-specific changes of T cell and macrophage populations in human achalasia.

Achalasia is a rare motility disorder of the esophagus caused by the gradual degeneration of myenteric neurons. Immune-mediated ganglionitis has been proposed to underlie the loss of myenteric neurons. Here, we measure the immune cell transcriptional profile of paired lower esophageal sphincter (LES) tissue and blood samples in achalasia and controls using single-cell RNA sequencing (scRNA-seq). In achalasia, we identify a pattern of expanded immune cells and a specific transcriptional phenotype, especially in LES tissue. We show C1QC+ macrophages and tissue-resident memory T cells (TRM), especially ZNF683+ CD8+ TRM and XCL1+ CD4+ TRM, are significantly expanded and localized surrounding the myenteric plexus in the LES tissue of achalasia. C1QC+ macrophages are transcriptionally similar to microglia of the central nervous system and have a neurodegenerative dysfunctional phenotype in achalasia. TRM also expresses transcripts of dysregulated immune responses in achalasia. Moreover, inflammation increases with disease progression since immune cells are more activated in type I compared with type II achalasia. Thus, we profile the immune cell transcriptional landscape and identify C1QC+ macrophages and TRM as disease-associated immune cell subsets in achalasia.

Single-cell transcriptomic analysis deciphers key transitional signatures associated with oncogenic evolution in human intramucosal oesophageal squamous cell carcinoma.

BACKGROUND AND AIMS: The early diagnosis and intervention of oesophageal squamous cell carcinoma (ESCC) are particularly important because of the lack of effective therapies and poor prognosis. Comprehensive research on early ESCC at the single-cell level is rare due to the need for fresh and high-quality specimens obtained from ESD. This study aims to systematically describe the cellular atlas of human intramucosal ESCC. METHODS: Five paired samples of intramucosal ESCC, para-ESCC oesophageal tissues from endoscopically resected specimens and peripheral blood mononuclear cells were adopted for scRNA-seq analysis. Computational pipeline scMetabolism was applied to quantify the metabolic diversity of single cells. RESULTS: A total of 164 715 cells were profiled. Epithelial cells exhibited high intra-tumoural heterogeneity and two evolutionary trajectories during ESCC tumorigenesis initiated from proliferative cells, and then through an intermediate state, to two different terminal states of normally differentiated epithelial cells or malignant cells, respectively. The abundance of CD8+ TEX s, Tregs and PD1+ CD4+ T cells suggested an exhausted and suppressive immune microenvironment. Several genes in immune cells, such as CXCL13, CXCR5 and PADI4, were identified as new biomarkers for poor prognosis. A new subcluster of malignant cells associated with metastasis and angiogenesis that appeared at an early stage compared with progressive ESCC was also identified in this study. Intercellular interaction analysis based on ligand-receptor pairs revealed the subcluster of malignant cells interacting with CAFs via the MDK-NCL pathway, which was verified by cell proliferation assay and IHC. This indicates that the interaction may be an important hallmark in the early change of tumour microenvironment and serves as a sign of CAF activation to stimulate downstream pathways for facilitating tumour invasion. CONCLUSION: This study demonstrates the changes of cell subsets and transcriptional levels in human intramucosal ESCC, which may provide unique insights into the development of novel biomarkers and potential intervention strategies.

Endoscopic submucosal dissection for gastric adenocarcinoma of the fundic gland type (chief cell predominate type): Four years' experience from a tertiary hospital.

OBJECTIVE: To summarize the endoscopic and clinicopathological features of gastric adenocarcinoma of the fundic gland type (GA-FG), and to evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for the treatment of GA-FGs. METHODS: From September 2017 to August 2021, patients treated with ESD who were pathologically confirmed to have GA-FGs were included. Those with lymphovascular and distal metastasis were excluded before ESD. The medical records were retrospectively reviewed to obtain information regarding patient demographics, clinicopathological characteristics, tumor features, complete resection rate, and complications, etc. All patients underwent follow-up for at least 12 months to evaluate any local recurrence or distant metastasis. RESULTS: A total of 15 patients with an average age of 56.9 ± 10.7 years were recruited, including 11 men and 4 women. Lesions were found at the upper third (13 [86.7%]) or middle third (2 [13.3%]) of the stomach. The average lesion size was 9.1 ± 4.8 mm. Macroscopically, lesions presented as a flat elevated type with reddish or erosion on top (n = 7, 46.7%), depressed type with pale color (n = 5, 33.3%), or submucosal tumor (SMT)-like appearance type (n = 3, 20.0%). En bloc resection, complete resection and curative resection were achieved in 14 (93.3%), 13 (86.7%), and 11 (73.3%) patients, respectively. Nine (60.0%) of the lesions had submucosal invasion. One patient underwent additional surgery. No local recurrence or metastasis was detected during the follow-up duration. CONCLUSIONS: GA-FGs present with various endoscopic features. ESD appears to be effective and safe for treating early-stage GA-FGs.

Utility of endoscopic ultrasound-guided fine-needle aspiration in pancreatic cancer patients who failed to obtain a pathological diagnosis in surgical exploration.

Background: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) allows for the analysis of diagnostic tissue specimens from various regions. For pancreatic tumors, especially un-resectable ones, how to obtain pathological confirmation is important for determining sub-sequent treatment. The purpose of this study is to investigate the clinical utility of EUS-FNA in patients who failed to obtain a pathological diagnosis in surgical exploration. Methods: Patients who underwent EUS-FNA due to unsuccessful biopsy in surgical exploration in our center were retrospectively reviewed. All of the patients were diagnosed with resectable disease before surgery but were found to be unresectable during surgery. The positive rate of pathological diagnosis of EUS-FNA was analyzed. Results: A total of 11 patients were included in this study, among which 8 were males and 3 were females. The median age of the patients was 55 years (range, 48 to 73 years). The median lesion size was 34 mm (range, 25 to 44 mm). The median number of needle passes was 3 (range, 1 to 3). Two patients underwent biliary stent implantation while 3 patients underwent gastrojejunostomy before EUS-FNA. The technical success rate of EUS-FNA was 100% (11/11); 10 (90.9%, 10/11) samples were positive and 1 was negative (being inadequate). Conclusions: Intraoperative biopsy is the first choice diagnostic modality for unresectable pancreatic neoplasms. However, for patients who fail to obtain a pathological diagnosis in surgical exploration, EUS-FNA is still worth an attempt.

Publication trends of peroral endoscopic myotomy during 2010-2022: a bibliometric analysis.

Background: Peroral endoscopic myotomy (POEM) has been rapidly accepted as a safe and effective therapy for achalasia and other esophageal motility disorders, and has inspired novel submucosal tunneling techniques. This study analyzed the trends in POEM research and compared contributions from different countries, regions, institutions, journals, and authors using bibliometric analysis to predict the trends and potential hotspots in POEM research. Methods: Publications concerning POEM from January 1, 2010 to February 25, 2022, were extracted from the Web of Science database. Book chapters, retrieved manuscripts, news, erratum, non-English language publications, and irrelevant publications were excluded. Data, including keywords for each article, were collected, and network analysis was conducted. Microsoft Excel and VOSviewer were used to collect publication data, analyze publication trends, and visualize relevant results. Results: A total of 1,853 publications were identified. Gastrointestinal Endoscopy has been the most popular journal in this field (n=383, 20.67%). Research from the United States was the largest contributor to POEM research worldwide and has provided a pivotal influence (n=743), followed by research from China (n=346) and Japan (n=223). Showa University (Japan) was the most active institution in the field of POEM research. In terms of authors, Dr. Inoue published the most papers in the field with the highest average citation number. Keywords were categorized into 5 clusters: management and outcomes, POEM-derived new techniques, diagnosis and classification, comparison with other treatment approaches, and fundoplication and POEM in children. Average appearing years of keywords was calculated. The topics of adverse events, gastroparesis, and gastric POEM (G-POEM) appeared most recently. Conclusions: Researchers from the United States, China, and Japan have published the most articles in the field of POEM research, but there was a disparity between the quantity and quality of publications. Research of management and POEM-derived novel techniques were considered potential areas of focus for future research.

Long-term outcomes of peroral endoscopic myotomy for achalasia in pediatric patients: a prospective, single-center study.

BACKGROUND: Peroral endoscopic myotomy (POEM) has been developed to provide a less-invasive myotomy for achalasia in adults but seldom has been used in pediatric patients. OBJECTIVE: To evaluate the feasibility, safety, and efficacy of POEM for pediatric patients with achalasia. DESIGN: Single-center, prospective study. SETTING: Academic medical center. PATIENTS: A total of 27 pediatric patients (mean age 13.8 years, range 6-17 years) with achalasia. INTERVENTIONS POEM MAIN OUTCOME MEASUREMENTS: The primary outcome was symptom relief during follow-up, defined as an Eckardt score of ≤3. Secondary outcomes were procedure-related adverse events, clinical reflux adverse events, and lower esophageal sphincter (LES) pressure on manometry before and after POEM. RESULTS: A total of 26 cases (96.3%) underwent successful POEM. A submucosal tunnelling attempt failed in 1 case because of serious inflammation and adhesion. No serious adverse events related to POEM were encountered. During a mean follow-up period of 24.6 months (range 15-38 months), treatment success was achieved in all patients (mean score before vs after treatment 8.3 vs 0.7; P < .001). Mean LES pressure also decreased from a mean of 31.6 mm Hg to 12.9 mm Hg after POEM (P < .001). Five patients developed clinical reflux adverse events (19.2%). LIMITATIONS: Single center and lack of some objective evaluations. CONCLUSION: This relatively long-term follow-up study adds to the evidence that POEM seems to be a promising new treatment for pediatric patients with achalasia, resulting in long-term symptom relief in all cases and without serious adverse events.

Overexpression of fibrinogen-like protein 2 induces epithelial-to-mesenchymal transition and promotes tumor progression in colorectal carcinoma.

The main cause of death in colorectal carcinoma (CRC) patients is tumor metastasis; however, the underlying molecular mechanisms are largely unknown. In the present study, a novel metastasis-related gene, fibrinogen-like protein 2 (FGL2), was characterized for its role in CRC metastasis and underlying molecular mechanisms. The clinical significance of FGL2 was investigated using tissue microarray analysis of samples from 82 patients with CRC. The molecular effects of FGL2 in CRC cells were determined using RNA interference and ectopic expression of FGL2. The overexpression of FGL2 was examined by immunohistochemistry in 82 CRC patients, and it was determined to be an independent predictor of overall survival (P < 0.05). The depletion of FGL2 expression inhibited tumor progression and epithelial-to-mesenchymal transition (EMT) in vitro and in vivo, while ectopic overexpression of FGL2 enhanced cell invasion and induced EMT in vitro. Our results suggest that FGL2 plays an important oncogenic role in CRC aggressiveness by inducing EMT, and FGL2 could be employed as a novel prognostic marker and effective therapeutic target for CRC.

[Analysis of associated factors of lymph node metastasis in intramucosal early gastric cancer].

OBJECTIVE: To analyze the associated predictive factors of lymph node metastasis in intramucosal early gastric cancer, and to provide reference for individualized treatment protocol. METHODS: Clinical data of 498 patients who were pathologically confirmed to be intramucosal early gastric cancer after radical resection of gastric cancer were retrospectively reviewed. Univariate and multivariate analyses were applied to evaluate the associated factors. RESULTS: Forty-three out of 498 patients (8.6%) had lymph node metastasis. Tumor size (HR=1.525, 95%CI:1.040-2.236), depth of invasion (HR=1.656, 95%CI:1.158-2.368) and histological type (HR=8.149, 95%CI:1.770-37.513) were the independent risk factors for lymph node metastasis in intramucosal early gastric cancer. CONCLUSIONS: Prediction and therapeutic guidance for lymph node metastasis in intramucosal early gastric cancer can be carried out according to clinicopathological risk factors.

[Feasibility of endoscopic resection for gastric gastrointestinal stromal tumor].

In recent years, with the development of digestive endoscopy, endoscopic submucosal dissection(ESD) and its derived techniques including endoscopic submucosal excavation(ESE), submucosal tunnelling endoscopic resection(STER) and laparoscopic endoscopic combined surgery(LECS), can cure most of the gastric gastrointestinal stromal tumor(GIST). This article reviews the indication, method and evaluation of endoscopic resection for gastric GIST.