Deep learning for gastroscopic images: computer-aided techniques for clinicians.

Gastric disease is a major health problem worldwide. Gastroscopy is the main method and the gold standard used to screen and diagnose many gastric diseases. However, several factors, such as the experience and fatigue of endoscopists, limit its performance. With recent advancements in deep learning, an increasing number of studies have used this technology to provide on-site assistance during real-time gastroscopy. This review summarizes the latest publications on deep learning applications in overcoming disease-related and nondisease-related gastroscopy challenges. The former aims to help endoscopists find lesions and characterize them when they appear in the view shed of the gastroscope. The purpose of the latter is to avoid missing lesions due to poor-quality frames, incomplete inspection coverage of gastroscopy, etc., thus improving the quality of gastroscopy. This study aims to provide technical guidance and a comprehensive perspective for physicians to understand deep learning technology in gastroscopy. Some key issues to be handled before the clinical application of deep learning technology and the future direction of disease-related and nondisease-related applications of deep learning to gastroscopy are discussed herein.

How to Perform Total Laparoscopic Duodenum-Preserving Pancreatic Head Resection Safely and Efficiently with Innovative Techniques.

BACKGROUND: Although rapid progress has been achieved in laparoscopic pancreaticoduodenectomy (PD) over the last decade, laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) remains a challenging surgery that has been rarely reported due to not only requiring complicated pancreaticojejunostomy (PJ) but also ensuring sufficient blood supplies to duodenum and common bile duct (CBD). We completed LDPPHR for 22 patients safely and efficiently with innovative techniques. PATIENTS AND METHODS: Clinical outcomes, including rate of conversion to laparotomy, time of residual pancreatic duct reconstruction, incidence of postoperative complications, and time of hospital stay, were collected for 22 consecutive patients who underwent LDPPHR with innovative techniques as follows: application of indocyanine green (ICG) to visualize and preserve CBD and the vessels supplying the duodenum and CBD, Hong's PJ, and pancreatic duct end-to-end anastomosis (ETEA) for the residual pancreas. RESULTS: All surgeries were performed successfully under laparoscopy except for one case. The duration of ETEA was significantly shorter than PJ (18.2 ± 5.1 min versus 27.5 ± 8.3 min, p < 0.05). There was no significant difference in incidence of postoperative complications between the Hong's PJ and ETEA group. The overall incidence of postoperative pancreatic fistula (POPF) in the Hong's PJ and ETEA group was 23.5% and 20%, respectively, without grade C fistula. All complications were resolved after conservative treatment. CONCLUSIONS: By utilizing intraoperative ICG navigation, LDPPHR is a minimally invasive, safe, and efficient approach for chronic pancreatitis with pancreatic head stones by using pancreatic duct ETEA and benign or low-grade malignant tumors of the pancreatic head by using Hong's PJ.

Histone Deacetylase 2 Stabilizes SPARC-related Modular Calcium Binding 2 to Promote Metastasis and Stemness in Gallbladder Cancer.

BACKGROUND: We aimed to investigate the relationship between histone deacetylase 2 (HDAC2) and SPARC-related modular calcium binding 2 (SMOC2) and the role of SMOC2 in gallbladder cancer (GBC). METHODS: The expression of HDAC2 and SMOC2 in GBC and normal cells was detected by quantitative real-time reverse transcription polymerase chain reaction (qRTPCR), which was also used to detect the mRNA stability of SMOC2. The combination between HDAC2 and SMOC2 was detected by Chromatin immunoprecipitation (ChIP) assay. After silencing and/or overexpressing HDAC2 and SMOC2, cell viability, migration, invasion, and stemness were respectively tested by the Cell Counting Kit-8 (CCK-8), cell scratch, transwell, and sphere-formation assay. RESULTS: In GBC cells, HDAC2 and SMOC2 were highly expressed. HDAC2 combined with SMOC2 promoted mRNA stability of SMOC2. HDAC2 or SMOC2 overexpression promoted GBC cell metastasis and stemness. SMOC2 overexpression rescued the negative effects of silencing HDAC2 in GBC. CONCLUSION: HDAC2 stabilizes SMOC2 to promote metastasis and stemness in gallbladder cancer.

Diagnostic Significance of Ultrasound-Guided Fine-Needle Aspiration Biopsy and on-Site Assessment by Pathologists for Thyroid Micronodules.

Objective: Ultrasound-guided fine-needle aspiration biopsy (US-FNAB) is a safe and effective method for screening malignant thyroid nodules. The purpose of this study was to compare the diagnostic effectiveness of US-FNAB for nodules of different sizes. Methods: A total of 1085 patients with thyroid nodules who underwent US-FNAB between January 2021 and July 2023 were included in the study. The patients were divided into three groups based on the maximum diameter of the nodules: there were 324 patients with thyroid nodules ≤5 mm in Group A, 537 patients with thyroid nodules between 6 mm and 10 mm in Group B, and 224 patients with thyroid nodules >10 mm in Group C. The US-FNAB satisfactory specimen rate, biopsy time and cytopathological results for the three groups were collected and compared with the postoperative pathological results. Results: The US-FNAB satisfactory specimen rates for Groups A, B and C were 84.57% (274/324), 90.13% (484/537) and 94.64% (212/224), respectively. The average biopsy times for Groups A, B, and C were 100.84 ± 41.58 s, 91.20 ± 32.53 s, and 79.01 ± 29.62 s, respectively. In Groups A, B, and C, 103, 192 and 73 patients, respectively, underwent surgery, and the malignancy rates were 88.35%, 85.42% and 72.6%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of US-FNAB in Group A were 78.26%, 81.82%, 97.30%, 31.03%; respectively; those in Group B were 73.78%,85.71%,96.80%, and 35.82%, respectively; and those in Group C were 75.47%, 85.00%, 93.02% and 56.67%, respectively. Conclusion: The US-FNAB satisfactory specimen rate for thyroid nodules ≤5 mm was relatively low, but the size of nodules had no effect on the diagnostic sensitivity of US-FNAB; additionally, nodules ≤5 mm had a higher probability of malignancy. Therefore, it is necessary to perform US-FNAB for thyroid nodules with a diameter ≤5 mm with malignant signs.

Orbital Rosai-Dorfman Disease in a fifty-eight years old woman.

Rosai-Dorfman disease (RDD) is rare and characterized by histiocytic proliferation and massive cervical lymphadenopathy. About 40% of patients have extra-nodal involvement. Opthalmic involvement is seen in 10% of cases. A case of orbital Rosai Dorfman disease in a 58 years old woman is presented here, who was misdiagnosed as orbital inflammatory disease initially. The patient did not respond to a course of oral prednisolone. Then complete surgical excision of the mass was performed and the histopathological examination was consistent with a diagnosis of RDD.

Mendelian randomization study highlights hypothyroidism as a causal determinant of alopecia areata.

Background: Although observational studies have found an association between hypothyroidism and alopecia areata, the causality of this relationship remains unclear. Objectives: This study aimed to investigate the genetic variants associated with hypothyroidism and their potential impact on the risk of developing alopecia areata. Methods: genome-wide association study summary statistics for hypothyroidism (30,155 cases and 379,986 controls) and alopecia areata (289 cases and 211,139 controls) were obtained from the IEU OpenGwas project. The inverse variance-weighted method was used as the primary analysis method to evaluate the causality between hypothyroidism and alopecia areata, supplemented by the weighted median, MR-Egger, simple mode and weighted mode. Furthermore, the function of causal SNPs was evaluated by gene ontology (GO) analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis, and protein-protein interaction networks. Result: Utilizing two-sample Mendelian randomization analysis, we found that the single-nucleotide polymorphisms (SNPs) of hypothyroidism (OR = 1.40, 95% CI: 1.12-1.75, p = 3.03×10-3) significantly increased the risk of alopecia areata ( 289 cases and 211,139 controls ). KEGG pathway analysis showed that the candidate genes were mainly enriched in virion-herpesvirus, Th1 and Th2 cell differentiation, Th17 cell differentiation, T-cell receptor signaling pathway, PD-L1/PD-1 checkpoint pathway in cancer and Toll-like receptor signaling pathway. Protein-protein interaction networks results showed that CTLA4, STAT4, IL2RA, TYK2, IRF7, SH2B3, BACH2, TLR3, NOD2, and FLT3. Conclusion: This study provided compelling genetic evidence supporting a causative association between hypothyroidism and alopecia areata, which could potentially inform the development of more efficacious treatment strategies for patients afflicted by alopecia areata.

Small bowel stricture complicating superior mesenteric vein thrombosis.

Superior mesenteric vein (SMV) thrombosis is a relatively rare disease. Most patients may be successfully treated with anti-coagulation alone. However, bowel stricture may develop due to intestinal ischemia which may require surgical treatment. This report describes a rare case of small bowel stricture occurring one month after successful treatment of SMV thrombosis. After segmental resection of strictured bowel, the patient's post-operative course was uneventful.

Identification of hub genes-based predictive model in hepatocellular carcinoma by robust rank aggregation and regression analysis.

Background: Though various hub genes for HCC have been identified in decades, the limited sample size, inconsistent bioinformatic analysis methods and lacking evaluation in validation cohorts would make the results less reliable, novel biomarkers and risk model for HCC prognosis are still urgently desired. Methods: The Robust Rank Aggression method was applied to integrate 12 HCC microarray datasets to screen for robustly and stably differentially expressed candidates. The Least Absolute Shrinkage and Selection Operator regression and multivariate Cox regression analysis were performed to construct a six hub genes-based prognostic model, which was further verified in matched tumor and non-tumor hepatic samples and two independent validation cohorts. Results: Six hub genes for HCC were identified including CD163, EHHADH, KIAA0101, SLC16A2, SPP1 and THBS4. The risk score according to hub genes-based prognostic model could be an independent predictive factor for HCC. Quantitative real-time polymerase chain reaction results showed significant difference in expression level between tumor and non-tumor hepatic tissues. Prognostic value of risk model has been verified in TCGA-HCC and GSE76240 datasets. Biological function analysis revealed these hub genes were closely associated with tumorigenesis processes. Conclusion: A novel six hub genes predictive risk model for HCC has been established based on multiple datasets analyses, providing novel features for the prediction of HCC patients' outcome.

Integrated bioinformatics analysis identified COL11A1 as an immune infiltrates correlated prognosticator in pancreatic adenocarcinoma.

Pancreatic adenocarcinoma (PAAD) is the most common pancreatic cancer, with high mortality rate and limited treatment options. Tumor infiltrating cells and genes in microenvironment are emerging as pivotal players in PAAD progression and prognosis. In this study, we obtained genes expression data set GSE119794 of PAAD, which contains data from 10 tumor and 10 normal samples. A total of 262 differentially expressed genes (DEGs), including 169 up-regulated and 93 down-regulated genes, were obtained based on expression fold change and significance. Combining the pathway analysis of DEGs and GSEA analysis of all genes, four KEGG pathways were enriched. The 4 pathways include pancreatic secretion, protein digestion and absorption, fat digestion and absorption, and PPAR signaling pathways. Functional enrichment of Gene Ontology significantly enriched extracellular matrix, an important component in microenvironment. In the Protein-protein interaction (PPI) network, we screened out 3 hub genes of COL11A1, KRT19 and CXCL5 by CytoHubba. At last, the expression level, prognostic significance and correlation with tumor infiltrates were validated in TCGA database, with GEPIA and TIMER. The validation identified Collagen Type XI Alpha 1 Chain (COL11A1), an extracellular matrix structural constituent, as a hazardous prognosticator with significant correlation with macrophage, neutrophil and dendritic cells. In sum, we identified COL11A1 as an immune infiltrates correlated prognosticator in pancreatic adenocarcinoma.

Agenesis of the gallbladder with adipose tissue in the gallbladder fossa.

Agenesis of the gallbladder with normal bile ducts is a rare anomaly. More cases have been reported preoperatively because of the increased awareness of this entity. However some cases remain difficult to diagnosis. We report such a case. A symptomatic male patient (age 45) was diagnosed with chronic atrophic cholecystitis and cholecystlithiasis by ultrasonography and computed tomography scan. The images revealed solid tissue in the gallbladder fossa. However, during laparoscopic exploration no gallbladder or ectopic gallbladder was found. Only adipose tissue and the gallbladder artery were identified during the operation. Gallbladder agenesis was diagnosed postoperatively. It still remains a challenge to determine surgical intervention in these cases.

CircRNA-SORE mediates sorafenib resistance in hepatocellular carcinoma by stabilizing YBX1.

Sorafenib is the first-line chemotherapeutic therapy for advanced hepatocellular carcinoma (HCC). However, sorafenib resistance significantly limits its therapeutic efficacy, and the mechanisms underlying resistance have not been fully clarified. Here we report that a circular RNA, circRNA-SORE (a circular RNA upregulated in sorafenib-resistant HCC cells), plays a significant role in sorafenib resistance in HCC. We found that circRNA-SORE is upregulated in sorafenib-resistant HCC cells and depletion of circRNA-SORE substantially increases the cell-killing ability of sorafenib. Further studies revealed that circRNA-SORE binds the master oncogenic protein YBX1 in the cytoplasm, which prevents YBX1 nuclear interaction with the E3 ubiquitin ligase PRP19 and thus blocks PRP19-mediated YBX1 degradation. Moreover, our in vitro and in vivo results suggest that circRNA-SORE is transported by exosomes to spread sorafenib resistance among HCC cells. Using different HCC mouse models, we demonstrated that silencing circRNA-SORE by injection of siRNA could substantially overcome sorafenib resistance. Our study provides a proof-of-concept demonstration for a potential strategy to overcome sorafenib resistance in HCC patients by targeting circRNA-SORE or YBX1.

Laparoscopic versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a single-center propensity score matching study.

Laparoscopic distal pancreatectomy (LDP) for benign and low-grade malignant pancreatic diseases has been increasingly utilized. However, the use of LDP for pancreatic ductal adenocarcinoma (PDAC) remains controversial and has not been widely accepted. In this study, the outcomes of LDP versus conventional open distal pancreatectomy (ODP) for left-sided PDAC were examined. A retrospective review of patients who underwent LDP or ODP for left-sided PDAC between January 2010 and January 2019 was conducted. One-to-one propensity score matching (PSM) was used to minimize selection biases by balancing factors including age, sex, ASA grade, tumor size, and combined resection. Demographic data, their pathological and short-term clinical parameters, and long-term oncological outcomes were compared between the LDP and ODP groups. A total of 197 patients with PDAC were enrolled. There were 115 (58.4%) patients in the LDP group and 82 (41.6%) patients in the ODP group. After 1:1 PSM, 66 well-matched patients in each group were evaluated. The LDP group had lesser blood loss (195 vs. 210 mL, p < 0.01), shorter operative time (193.6 vs. 217.5 min; p = 0.02), and shorter hospital stay (12 vs. 15 days, p < 0.01), whereas the overall complication rates were comparable between groups (10.6% vs.16.7%, p = 0.31). There were no significant differences between the LDP and ODP groups regarding 3-year recurrence-free or overall survival rate (p = 0.89 and p = 0.33, respectively). LDP in the treatment of left-sided PDAC is a technically safe, feasible and favorable approach in short-term surgical outcomes. Moreover, patients undergoing LDP than ODP for PDAC had comparable oncological metrics and similar middle-term survival rate.

Androgen receptor affects the response to immune checkpoint therapy by suppressing PD-L1 in hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is a heterogeneous malignancy with gender-related differences in onset and course. Androgen receptor (AR), a male hormone receptor, is critical in the initiation and progression of HCC. The role of AR in HCC has been mechanistically characterized and anti-AR therapies have been developed, showing limited efficacy. Immunotherapy targeting immune checkpoint proteins may substantially improve the clinical management of HCC. The mechanism by which AR influences HCC immune state remains unclear. In this study, we demonstrated that AR negatively regulated PD-L1, by acting as a transcriptional repressor of PD-L1. Notably, AR over-expression in HCC cells enhanced CD8+T function in vitro. We then verified the AR/PD-L1 correlation in patients. In animal experiment we found that lower AR expressed tumor achieved better response to PD-L1 inhibitor. Thus, AR suppressed PD-L1 expression, possibly contributing to gender disparity in HCC. Better understanding of the roles of AR during HCC initiation and progression will provide a novel angle to develop potential HCC immunotherapies.

[Laparoscopic radical resection for gallbladder carcinoma].

OBJECTIVE: To evaluate the feasibility and efficacy of laparoscopic radical resection of gallbladder carcinoma. METHODS: The clinical feature, pathological stage, surgical procedure, postoperative recovery and follow-up results of 4 patients undergoing laparoscopic radical resection of gallbladder carcinoma were retrospectively analyzed. RESULTS: A total of 4 cases were successfully performed. No operative deaths and complications happened. Two patients died of recurrence at 17 and 40 months respectively. There were no port-site and abdominal wall metastases occurred. CONCLUSION: Laparoscopic radical resection of gallbladder carcinoma is a safe and feasible procedure on basis of technique. Nonetheless prospective randomization study with a greater number of cases and a longer follow-up will be needed to evalut the long-term results of it.

[Laparoscopic resection of Spiegel lobe].

OBJECTIVE: To evaluate the feasibility and experience of laparoscopic resection for Spiegel lobe associated with left liver lobe. METHODS: Three patients underwent laparoscopic resection of Spiegel lobe associated with left liver lobe. Left hemihepatectomy or left lateral lobectomy was carried out firstly and then Spiegel lobe resected through the left-sided approach. RESULTS: A total of 3 cases were performed successfully. The median operative time was 197 min and the median blood loss 467 ml. The postoperative period was uneventful without hemorrhage, bile leakage, infection or abdominal effusion. CONCLUSION: Laparoscopic resection of Spiegel lobe associated with left liver lobe is safe and feasible when performed in selected cases and by experienced surgeons in laparoscopic hepatectomy.

Integrated analysis of hypoxia-induced miR-210 signature as a potential prognostic biomarker of hepatocellular carcinoma: a study based on The Cancer Genome Atlas.

Hepatocellular carcinoma (HCC) is one of the most common types of liver cancer and is the second leading cause of cancer mortality with an estimated 745 500 deaths annually (Jemal et al., 2011). Although new therapeutic modalities including novel chemotherapeutic interventions and targeted therapy have been applied, the prognosis of HCC patients remains unsatisfactory due to the high incidence of intrahepatic and distal metastases (Siegel et al., 2018).

Laparoscopic Right Hepatectomy for Hepatocellular Carcinoma: A Propensity Score Matching Analysis of Outcomes Compared with Conventional Open Surgery.

BACKGROUND: The application of laparoscopic hepatectomy is gaining momentum. However, the safety and efficacy of laparoscopic right hepatectomy (LRH) on hepatocellular carcinoma (HCC) are yet to be adequately evaluated. We aimed to assess the surgical and oncological outcomes of LRH for HCC by comparing it with open right hepatectomy (ORH). MATERIALS AND METHODS: Data of patients who underwent hepatectomy for HCC from May 2007 to January 2018 in our hospital were obtained. Baseline characteristics, postoperative recovery, and survival outcomes were compared. One-to-one propensity score matching (PSM) was used to minimize selection biases by balancing factors, including age, sex, preoperative therapy, tumor size, and pattern. RESULTS: The original cohort included 109 patients (LRH, 41 patients; ORH, 68 patients). Of the 41 patients who underwent LRH, 8 patients (19.5%) required conversion to laparotomy. The overall morbidity was 19.5%, and no mortality in LRH was noted. After PSM, LRH was associated with a tendency of prolonged operative time (255.5 ± 93.4 minutes versus 225.9 ± 39.8 minutes, P = .08) and less intraoperative blood loss [300 (100-1200) versus 500 (200-2000) mL, P < .01]. LRH showed up a trend of less overall morbidity without statistical significance (18.4% versus 26.3%, P = .41). Moreover, the 3-year overall and disease-free survival did not differ significantly between the groups during a median follow-up of 19 (3-58) months for the LRH group and 23 (3-97) months for the ORH group. CONCLUSIONS: LRH can be performed as safe and effective as ORH for HCC in regard to both surgical and oncological outcomes. LRH holds the benefit in less intraoperative blood loss and appears to achieve less postoperative morbidity, which could serve as a promising alternative to ORH in selected individuals.

High RNF40 expression indicates poor prognosis of hepatocellular carcinoma.

Human RING-finger protein 40 (RNF40) is reported as an E3 ligase of H2B ubiquitination. RNF40 needs to couple with its homolog RNF20 to format a complex to regulate DNA double strand break (DSB) response and chromatin stability. Deficient expression of RNF40 might cause incorrect DNA repair and contribute to genomic instability, leading to an abnormal transcriptional program. Incorrect DSB repair and aberrant gene transcription play important roles in tumorigenesis. The role in primary hepatocellular carcinoma (HCC), however, remains unclear. In this study, we selected 103 cases of HCC for immunohistochemistry to explore the role of RNF40 in HCC. The relationship between RNF40 expression and clinicopathological features of HCC was evaluated. RNF40 was mainly localized in the nucleus, where the percentage of low and high staining of RNF40 in tumor tissues was 50.4% (53/103) and 49.6% (50/103), respectively. By contrast, in para-normal tissues the percentage was 92.2% (95/103) and 7.8% (8/103) respectively. Expression of RNF40 in tumor tissues was significantly higher than that in para-normal tissues (P>0.01). Expression of RNF40 had significant association with AFP and TNM tumor stage (both P>0.01). However, age, gender, Hepatitis B Virus infection, liver cirrhosis, tumor size, tumor number, differential stage, and tumor thrombosis were not associated with RNF40 expression. Meanwhile, HCC patients with high expression of RNF40 had lower 5 year overall survival rates and disease-free survival rates (P>0.05). RNF40 is, potentially, an independent prognostic factor for survival in HCC.

High expression of ERCC5 predicts a poor prognosis in hepatocellular carcinoma.

Human cells exposed to environmental or endogenous carcinogens can develop DNA damage. This DNA damage may contribute to a susceptibility to cancer; therefore, it is important to repair these defects. The nucleotide excision repair pathway (NER) is a versatile DNA repair pathway that eliminates a wide variety of helix-distorting base lesions induced by environmental or endogenous carcinogenic sources. The excision repair cross-complementation group 5 (ERCC5) gene is a central component of NER. Ectopic expression of ERCC5 has been linked to different types of cancers, including hepatocellular carcinoma (HCC). However, previous reports, mainly based on mRNA level and the role of ERCC5 in cancer, remain conflicting and unclear. In this study, we examined 104 cases of HCC for immunohistochemistry to explore the role of ERCC5 protein in HCC. We found the expression of ERCC5 protein was significantly increased in tumor tissues compared to paracancerous ones (P<0.01). The percentage of positive staining of ERCC5 in tumor tissues was 28.8% (30/104), while only 4.8% (5/104) in paracancerous tissues. Patients with low ERCC5 expression levels had a better overall survival rate and remained disease-free longer (both P<0.01). In addition, univariate and multivariate analysis showed a high expression of ERCC5 protein and large tumor size predict a poor prognosis for patients with HCC (P<0.05).

Comparison of Intracorporeal and Extracorporeal Esophagojejunostomy after Laparoscopic Total Gastrectomy for Gastric Cancer: A Meta-Analysis Based on Short-Term Outcomes.

BACKGROUND:: Laparoscopic total gastrectomy (LTG) is increasingly performed in patients with gastric cancer. However, the usage of intracorporeal esophagojejunostomy (IEJ) following LTG is limited, as the safety and efficacy remain unclear. The present meta-analysis aimed to evaluate the feasibility and safety of IEJ following LTG. METHODS:: Studies published from January 1994 to January 2017 comparing the outcomes of IEJ and extracorporeal esophagojejunostomy (EEJ) following LTG were reviewed and collected from the PubMed, EBSCO, Cochrane Library, Embase, and China National Knowledge Internet (CNKI). Operative results, postoperative recovery, and postoperative complications were compared and analyzed. The weighted mean difference (WMD) and odds ratio (OR) with a 95% confidence interval (CI) were calculated using the Review Manager 5.3. RESULTS:: Seven nonrandomized studies with 785 patients were included. Compared with EEJ, IEJ has less blood loss (WMD: -13.52 ml; 95% CI: -24.82--2.22; P = 0.02), earlier time to first oral intake (WMD: -0.49 day; 95% CI: -0.83--0.14; P < 0.01), and shorter length of hospitalization (WMD: -0.62 day; 95% CI: -1.08--0.16; P < 0.01). There was no significant difference between IEJ and EEJ regarding the operation time, anastomotic time, number of retrieved lymph nodes, time to first flatus, anastomosis leakage rate, anastomosis stenosis rate, and proximal resections (all P > 0.05). CONCLUSIONS: Compared with EEJ, IEJ has better cosmesis, milder surgical trauma, and a faster postoperative recovery. IEJ can be performed as safely as EEJ. IEJ should be encouraged to surgeons with sufficient expertise.