Myotomy length informed by high-resolution esophageal manometry (HREM) results in improved per-oral endoscopic myotomy (POEM) outcomes for type III achalasia.

INTRODUCTION: High-resolution esophageal manometry (HREM) is essential in characterizing achalasia subtype and the extent of affected segment to plan the myotomy starting point during per-oral endoscopic myotomy (POEM). However, evidence is lacking that efficacy is improved by tailoring myotomy to the length of the spastic segment on HREM. We sought to investigate whether utilizing HREM to dictate myotomy length in POEM impacts postoperative outcomes. METHODS: Comparative analysis of HREM-tailored to non-tailored patients from a prospectively collected database of all POEMs at our institution January 2011 through July 2017. A tailored myotomy is defined as extending at least the length of the diseased segment, as initially measured on HREM. RESULTS: Forty patients were included (11 tailored versus 29 non-tailored). There were no differences in patient age (p = 0.6491) or BMI (p = 0.0677). Myotomy lengths were significantly longer for tailored compared to non-tailored overall (16.6 ± 2.2 versus 13.5 ± 1.8; p < 0.0001), and for only type III achalasia (15.9 ± 2.4 versus 12.7 ± 1.2; p = 0.0453), likely due to more proximal starting position in tailored cases (26.0 ± 2.2 versus 30.0 ± 2.7; p < 0.0001). Procedure success (Eckardt < 3) was equivalent across groups overall (p = 0.5558), as was postoperative Eckardt score (0.2 ± 0.4 versus 0.8 ± 2.3; p = 0.4004). Postoperative Eckardt score was significantly improved in the tailored group versus non-tailored for type III only (0.2 ± 0.4 versus 1.3 ± 1.5; p = 0.0435). A linear correlation was seen between increased length and greater improvement in Eckardt score in the non-tailored group (p = 0.0170). CONCLUSIONS: Using HREM to inform surgeons of the proximal location of the diseased segment resulted in longer myotomies, spanning the entire affected segment in type III achalasia, and in lower postoperative Eckardt scores. Longer myotomy length is often more easily achieved with POEM than with Heller myotomy, which raises the question of whether POEM results in better outcomes for type III achalasia, as types I and II do not generally have measurable spastic segments.

Interleukin-28B and fibrosing cholestatic hepatitis in posttransplant hepatitis C: a case-control study and literature review.

Chronic hepatitis C (CHC)-related cirrhosis is the leading indication for liver transplantation (LT). However, the recurrence of a hepatitis C virus (HCV) infection after transplantation is universal and is associated with worse outcomes. Fibrosing cholestatic hepatitis (FCH) is a particularly severe manifestation of a recurrent HCV infection and frequently results in graft failure and death. The identification of risk factors for FCH is important but has been limited by the low frequency of FCH. The interleukin-28B (IL-28B) genotype is important in an HCV infection: it is related to the clinical severity of an acute infection and may play a role in the development of FCH as well. Two hundred seventy-two consecutive LT cases for CHC were studied at a single institution. Consensus criteria were used to define an FCH cohort. The remainder of the study population served as a control group. The IL-28B genotype (at the rs12979860 locus) from both the donor and the recipient was determined, and other clinically relevant data were tabulated. A nonparametric statistical analysis was performed. Twelve cases of FCH were identified, and they were compared to a control group of 260 LT cases without FCH. A detailed analysis of clinical characteristics, including treatment responses and outcomes, was tabulated. FCH was associated with the earlier recurrence of HCV infections, higher HCV viral loads, and lower levels of immunosuppressive medications. There was a nonsignificant increase in recipient IL-28B non-CC genotypes in cases developing FCH. In conclusion, a high HCV viral load and earlier recurrence were identified as risk factors for FCH. It is still unclear what role immunosuppression plays in the pathogenesis of FCH and whether IL-28B polymorphisms constitute a risk factor. Collaborative studies with larger numbers of study subjects are needed in order to define these issues.

Treatment of Achalasia with Per-Oral Endoscopic Myotomy: Analysis of 50 Consecutive Patients.

BACKGROUND: Peroral endoscopic myotomy (POEM) has become an acceptable incisionless treatment for achalasia based on encouraging outcomes in multiple series worldwide. This report reflects our early experience. METHODS: Data were collected prospectively on all patients undergoing POEM between June 2011 and April 2016 under IRB approval. Diagnosis of achalasia was confirmed by standard preoperative work-up. Primary outcome was symptom relief, measured by Eckardt score. Secondary outcomes were operative time, length of stay (LOS), adverse events, failure, and recurrence. RESULTS: Fifty patients were included; 30 were female. Mean age was 55.7 ± 17.7 years. Mean BMI was 29.5 ± 9.2. Median OR time was 133.5 minutes (range 70-462); average myotomy was 13.1 ± 2.3 cm. One early case was converted to a laparoscopic Heller myotomy due to extensive submucosal fibrosis from a recent Botox injection. Two cases were aborted; one due to extensive submucosal fibrosis and the other to intraoperative capnopericardium. Median LOS was 1 day (range 0.8-8). Two major complications occurred: intraoperative cardiac arrest due to capnopericardium and postoperative submucosal hemorrhage. There were no deaths. Mean postoperative Eckardt score was 1.0 ± 1.9 (range 0-8) at 2-6 weeks (vs. preoperative score 7.7 ± 2.8; P < .0001); mean dysphagia component 0.35 ± 0.28 (vs. preoperative score 2.6 ± 0.7; P < .0001). Two recurrences were identified, both at 6 months. CONCLUSIONS: POEM is a safe and durable treatment for achalasia in the short term. We demonstrated marked improvement of symptoms in all completed cases. There was an acceptable serious adverse event rate of 4%, failure of 6% due to patient selection, and recurrences occurring in only 4% of cases.

Microarray analysis of trophoblast cells.

A complex repertoire of trophoblast gene products governs the multifaceted functions performed by the placenta during the relatively short period of pregnancy. Cloning and sequencing the human as well as other mammalian genomes allow investigators to gain better insight into the function of trophoblast genes. Our ability to identify transcripts by their nucleotide sequences and determine their expression patterns enables us to glean information on gene function. Although the molecular principles underlying microarray are not new to biology, the high throughput, low reaction volumes, fluorescent labeling, accurate detection, and robust analysis software makes this approach most appealing to today's researchers, when compared with standard filter blotting techniques. This chapter focuses on DNA microarray of the human placental transcriptome as a means to identify alterations in gene expression in different physiological or pathological conditions.

Recurrent Obstructive Giant Inflammatory Polyposis of the Colon.

Inflammatory polyps are relatively common in patients with inflammatory bowel disease. The term giant inflammatory polyposis is used to describe inflammatory polyps greater than 1.5 cm in any dimension. Their clinical presentation can be varied, ranging from asymptomatic, with incidental detection on radiological or endoscopic testing, to symptomatic, with rectal bleeding and colonic obstruction. Although giant inflammatory polyposis is a rare finding, it is of clinical importance, since it is easily mistaken for colon cancer, with patients sometimes undergoing radical surgeries. We describe an unusual case of giant inflammatory polyposis causing recurrent symptomatic obstruction despite multiple segmental colectomies in a patient with indeterminate colitis. This is the first such reported case in English literature to the best of our knowledge.

A variable fold change threshold determines significance for expression microarrays.

The use of expression microarrays to determine bona fide changes in gene expression between experimental paradigms is confounded by noise due to variability in measurement. To assess the variability associated with transcript hybridization to commercial oligonucleotide-based microarrays, we generated a data set consisting of five replicate hybridizations of a single labeled cRNA target from three distinct experimental paradigms, using the Affymetrix human U95 GeneChip set. We found that the variability of expression level in our data set is intensity-specific. We quantified the observed variability in our data set in order to determine significant changes in gene expression. LOESS fitting to a plot of the standard deviation of replicates assigned a variability associated with a specific intensity. This allowed for the calculation of a "variable fold-change" threshold for any absolute intensity at any level of statistical confidence. Testing of this method indicates that it removes intensity-specific bias and results in a 5- to 10-fold reduction in the number of false-positive changes. We suggest that this approach can be widely used to improve prediction of significant changes in gene expression for oligonucleotide-based microarray experiments and reduce false leads, even in the absence of replicates.

Tumor heterogeneity affects the precision of microarray analysis.

Microarray-based analysis of global gene expression patterns defines groups of genes that correlate with specific tumor types and prognosis, but the identified genes may not all be of equal clinical utility due to technical factors that affect the precision of their measurement. To analyze how technical variability in measured expression levels may impact microarray-based analysis in a clinical setting, we used Ewing sarcoma/peripheral neuroectodermal tumor (EWS/PNET) in a model system that replicates the clinical scenario in which microarray-based analysis of gene expression will likely occur, namely analysis of a fresh tumor sample by a single chip. By comparing variability of measured expression due to purely technical factors with variability due to biologic factors, we confirm that variability is dependent on the level of gene expression. We also demonstrate that the variability in expression level from either cell line or tumor samples is significantly higher than can be attributed to specific probe sets that have an intrinsically poor performance. These results have significant impact on the application of cDNA microarray chip for molecular analysis performed in a clinical setting.

Incorporation of gene-specific variability improves expression analysis using high-density DNA microarrays.

BACKGROUND: The assessment of data reproducibility is essential for application of microarray technology to exploration of biological pathways and disease states. Technical variability in data analysis largely depends on signal intensity. Within that context, the reproducibility of individual probe sets has not been hitherto addressed. RESULTS: We used an extraordinarily large replicate data set derived from human placental trophoblast to analyze probe-specific contribution to variability of gene expression. We found that signal variability, in addition to being signal-intensity dependant, is probe set-specific. Importantly, we developed a novel method to quantify the contribution of this probe set-specific variability. Furthermore, we devised a formula that incorporates a priori-computed, replicate-based information on probe set- and intensity-specific variability in determination of expression changes even without technical replicates. CONCLUSION: The strategy of incorporating probe set-specific variability is superior to analysis based on arbitrary fold-change thresholds. We recommend its incorporation to any computation of gene expression changes using high-density DNA microarrays. A Java application implementing our T-score is available at http://www.sadovsky.wustl.edu/tscore.html.