Efficacy and safety of piecemeal submucosal tunneling endoscopic resection for giant esophageal leiomyoma.

BACKGROUND AND AIMS: Giant esophageal leiomyoma usually requires a thoracotomy or thoracoscopic surgery, which is more invasive than an endoscopic treatment. The purpose of this study is to evaluate the efficacy and safety of piecemeal submucosal tunneling endoscopic resection (P-STER) for giant leiomyoma originating from the muscularis propria (MP) layer of the esophagus. METHODS: This is a retrospective study. Patients with giant esophageal leiomyoma (transverse diameter ≥ 3 cm) who underwent P-STER were enrolled from November 2012 to May 2023. Clinical data and results were investigated. RESULTS: A total of 16 patients were enrolled for analysis. The lesion mean transverse diameter and longitudinal diameter were 4.22 ± 1.20 cm and 6.20 ± 1.57 cm, respectively. Our mean operation time was 195.38 ± 84.99 min. The mean number of piecemeal resected was 4.31 ± 2.36. An adverse event noted was an esophageal fistula that occurred in one case (6.25%) and was treated conservatively. The mean length of hospital stay was around 11.81 ± 7.30 days. The mean total hospitalization cost was U.S. dollars (USD) $5976.50 ± 2866.39. No recurrence or metastasis was found during the follow-up period. CONCLUSIONS: P-STER can be an effective and safe treatment for giant leiomyoma originating from the MP layer of the esophagus.

Development and Validation of an Artificial Intelligence Model for Small Bowel Capsule Endoscopy Video Review.

Importance: Reading small bowel capsule endoscopy (SBCE) videos is a tedious task for clinicians, and a new method should be applied to solve the situation. Objectives: To develop and evaluate the performance of a convolutional neural network algorithm for SBCE video review in real-life clinical care. Design, Setting, and Participants: In this multicenter, retrospective diagnostic study, a deep learning neural network (SmartScan) was trained and validated for the SBCE video review. A total of 2927 SBCE examinations from 29 medical centers were used to train SmartScan to detect 17 types of CE structured terminology (CEST) findings from January 1, 2019, to June 30, 2020. SmartScan was later validated with conventional reading (CR) and SmartScan-assisted reading (SSAR) in 2898 SBCE examinations collected from 22 medical centers. Data analysis was performed from January 25 to December 31, 2021. Exposure: An artificial intelligence-based tool for interpreting clinical images of SBCE. Main Outcomes and Measures: The detection rate and efficiency of CEST findings detected by SSAR and CR were compared. Results: A total of 5825 SBCE examinations were retrospectively collected; 2898 examinations (1765 male participants [60.9%]; mean [SD] age, 49.8 [15.5] years) were included in the validation phase. From a total of 6084 CEST-classified SB findings, SSAR detected 5834 findings (95.9%; 95% CI, 95.4%-96.4%), significantly higher than CR, which detected 4630 findings (76.1%; 95% CI, 75.0%-77.2%). SmartScan-assisted reading achieved a higher per-patient detection rate (79.3% [2298 of 2898]) for CEST findings compared with CR (70.7% [2048 of 2298]; 95% CI, 69.0%-72.3%). With SSAR, the mean (SD) number of images (per SBCE video) requiring review was reduced to 779.2 (337.2) compared with 27 910.8 (12 882.9) with CR, for a mean (SD) reduction rate of 96.1% (4.3%). The mean (SD) reading time with SSAR was shortened to 5.4 (1.5) minutes compared with CR (51.4 [11.6] minutes), for a mean (SD) reduction rate of 89.3% (3.1%). Conclusions and Relevance: This study suggests that a convolutional neural network-based algorithm is associated with an increased detection rate of SBCE findings and reduced SBCE video reading time.

In vitro and in vivo evaluation of DC-targeting PLGA nanoparticles encapsulating heparanase CD4+ and CD8+ T-cell epitopes for cancer immunotherapy.

Heparanase has been identified as a universal tumor-associated antigen, but heparanase epitope peptides are difficult to recognize. Therefore, it is necessary to explore novel strategies to ensure efficient delivery to antigen-presenting cells. Here, we established a novel immunotherapy model targeting antigens to dendritic cell (DC) receptors using a combination of heparanase CD4+ and CD8+ T-cell epitope peptides to achieve an efficient cytotoxic T-cell response, which was associated with strong activation of DCs. First, pegylated poly(lactic-coglycolic acid) (PLGA) nanoparticles (NPs) were used to encapsulate a combined heparanase CD4+ and CD8+ T-cell epitope alone or in combination with Toll-like receptor 3 and 7 ligands as a model antigen to enhance immunogenicity. The ligands were then targeted to DC cell-surface molecules using a DEC-205 antibody. The binding and internalization of these PLGA NPs and the activation of DCs, the T-cell response and the tumor-killing effect were assessed. The results showed that PLGA NPs encapsulating epitope peptides (mHpa399 + mHpa519) could be targeted to and internalized by DCs more efficiently, stimulating higher levels of IL-12 production, T-cell proliferation and IFN-γ production by T cells in vitro. Moreover, vaccination with DEC-205-targeted PLGA NPs encapsulating combined epitope peptides exhibited higher tumor-killing efficacy both in vitro and in vivo. In conclusion, delivery of PLGA NP vaccines targeting DEC-205 based on heparanase CD4+ and CD8+ T-cell epitopes are suitable immunogens for antitumor immunotherapy and have promising potential for clinical applications.

Fully automated magnetically controlled capsule endoscopy for examination of the stomach and small bowel: a prospective, feasibility, two-centre study.

BACKGROUND: The use of magnetically controlled capsules for gastroscopy is in the early stages of clinical adoption. We aimed to evaluate the safety and efficacy of a fully automated magnetically controlled capsule endoscopy (FAMCE) system in clinical practice for gastroscopy and small bowel examination. METHODS: We did a prospective, comparative study to evaluate the safety and efficacy of FAMCE. Patients from two hospitals in Chongqing, China were consecutively enrolled. Eligible participants were aged 18-80 years with suspected gastric pathology and no previous surgery. Participants underwent FAMCE for screening of gastric lesions, then conventional transoral gastroscopy 2 h later, and stomach examination results were compared. The primary outcome was the rate of complete detection of gastric anatomy landmarks (cardia, fundus, body, angulus, antrum, and pylorus) by FAMCE. Secondary outcomes were the time required for gastric completion by FAMCE, the rate of detection of gastric lesions by FAMCE compared with conventional transoral gastroscopy, and the rate of complete small bowel examination. Adverse events were also evaluated. The study was registered in the Chinese Clinical Trial Registry, ChiCTR2000040507. FINDINGS: Between May 12 and Aug 17, 2020, 114 patients (mean age 44·0 years [IQR 34·0-55·0]; 63 [55%] female) were enrolled. The rate of complete detection of gastric anatomical structures by FAMCE was 100% (95% CI 99·3-100·0). The concordance between FAMCE and conventional transoral gastroscopy was 99·61% (99·45-99·78). The mean completion time of a gastroscopy with FAMCE was 19·17 min (SD 1·43; median 19·00, IQR 19·00-20·00), compared with 5·21 min (2·00; 5·18, 3·68-6·45) for conventional transoral gastroscopy. In 114 enrolled patients, 214 lesions were detected by FAMCE and conventional transoral gastroscopy. Of those, 193 were detected by both modalities. FAMCE missed five pathologies (four cases of gastritis and one polyp), whereas conventional transoral gastroscopy missed 16 pathologies (12 cases of gastritis, one polyp, one fundal xanthoma, and two antral erosions). FAMCE was able to provide a complete small bowel examination for all 114 patients and detected intestinal lesions in 50 (44%) patients. During the study, two (2%) patients experienced adverse events. No serious adverse events were recorded, and there was no evidence of capsule retention. INTERPRETATION: The performance of FAMCE is similar to conventional transoral gastroscopy in completion of gastric examination and lesion detection. Furthermore, it can provide a complete small bowel examination. Therefore, FAMCE could be effective method for examination of the gastrointestinal tract. FUNDING: Chinese National Key Research and Development Program.

Current applications and future prospects of nanomaterials in tumor therapy.

Tumors are one of the most serious human diseases and cause numerous global deaths per year. In spite of many strategies applied in tumor therapy, such as radiation therapy, chemotherapy, surgery, and a combination of these treatments, tumors are still the foremost killer worldwide among human diseases, due to their specific limitations, such as multidrug resistance and side effects. Therefore, it is urgent and necessary to develop new strategies for tumor therapy. Recently, the fast development of nanoscience has paved the way for designing new strategies to treat tumors. Nanomaterials have shown great potential in tumor therapy, due to their unique properties, including passive targeting, hyperthermia effects, and tumor-specific inhibition. This review summarizes the recent progress using the innate antitumor properties of metallic and nonmetallic nanomaterials to treat tumors, and related challenges and prospects are discussed.

Application of clip traction in endoscopic submucosal dissection to the treatment of early esophageal carcinoma and precancerous lesions.

BACKGROUND AND AIM: It is usually difficult to obtain a good view of the dissection plane during esophageal endoscopic submucosal dissection (ESD). Therefore, the aim of this study was to investigate the efficacy and safety of clip traction in ESD for the treatment of early esophageal carcinoma (EEC) or precancerous lesions. METHODS: This is a case-matched comparative study. We selected 100 EEC patients who had undergone ESD. Fifty cases underwent ESD without clip traction (non-clip group), and 50 cases underwent ESD with clip traction (clip group). The patient-related variables, dissection time, data regarding muscularis propria injury, etc. were statistically analyzed. RESULTS: ESD was successful in all cases without complication. There were no significant differences between the two groups with respect to age, gender, the longitudinal diameter of the lesions, etc. Wide visual field exposure of the submucosal tissue below the lesion was obtained by applying clip traction. The dissection time of ESD was shorter in the clip group than in the non-clip group [22.02 (6.77) min vs 26.48 (12.56); P = 0.018] when the extent of lesion was less than half of the circumference of the esophagus; otherwise, there was no difference between the two groups (P = 0.252). Moreover, the muscularis propria injuries in the clip group were obviously less than the non-clip group (10 vs 30 %, P = 0.007). CONCLUSION: Clip traction can decrease the rate of muscularis propria injury and shorten the dissection time. It is recommended as a safe and effective auxiliary procedure for the treatment of esophageal ESD.

Endoscopic submucosal dissection for superficial esophageal cancer with near-circumferential lesions: our experience with 40 patients.

BACKGROUND: Nowadays, there are few reports indicating whether early esophageal cancers (EsC) with near-circumferential lesions are still appropriate for the endoscopic submucosal dissection (ESD) procedure. METHODS: Between November 2009 and December 2013, a total of 40 patients with early esophageal cancers were treated with ESD. The characteristics of the patients, the ESD procedure variables, the rates of en bloc resection, and the major complications were evaluated. The outcomes listed were reliably followed up, and postoperative endoscopic balloon dilation was conducted to treat the esophageal strictures. RESULTS: A total of 40 patients with superficial esophageal cancers were treated with ESD procedure. The extent of the lesions as a proportion of the whole circumference of the esophageal lumen ranged from three-quarters (18/40) to four-fifths (4/40) and complete circumference (18/40). The median longitudinal diameter of the lesions was 50 mm. The median procedure time was 92.5 min (range, 70-125 min). The en bloc resection rate was 100 % (40/40). Immediate bleeding, perforation, and postoperative stenosis were noted in 7.5 (3/40), 7.5 (3/40), and 45 % (18/40) of the patients. The median number of endoscopic balloon dilations (EBDs) was 4 (range 1-14). Additional surgical treatment was performed in 2 cases, and local recurrence was detected in 1 patient (2.5 %). 2 patients (5 %) died of EsC 3 months after ESD. CONCLUSIONS: These data will greatly expand the criteria for the use of ESD in esophageal cancer and increase the number of patients eligible for endoscopic treatment and the acceptance of the ESD procedure.

Small Bowel Endoscopy Diagnostic Yield and Reasons of Obscure GI Bleeding in Chinese Patients.

Aim. To investigate the diagnostic yield and etiologies of patients with obscure gastrointestinal bleeding (OGIB) using capsule endoscopy (CE) or double-balloon enteroscopy (DBE). Method. We studied the data of 532 consecutive patients with OGIB that were referred to Xinqiao Hospital in Chongqing from December 2005 to January 2012. A lesion that was believed to be the source of the bleeding (ulceration, mass lesion, vascular lesion, visible blood, inflammation, or others) was considered to be a positive finding. We analyzed the diagnostic yield of CE and SBE and the etiologies of OGIB. Result. CE and SBE have similar diagnostic yields, at 71.9% (196/231) and 71.8% (251/304), respectively. The most common etiology was erosions/ulceration (27.1%) followed by mass lesion (19.4%) and angiodysplastic/vascular lesions (13.9%). By stratified analysis, we found that erosions/ulceration (27.1%) was the most common etiology for the 21-40-year age group. Mass lesion was the most common etiology in the 41-60-year age group. However, in the >60 years age group, angiodysplastic/vascular lesions were significantly increased compared with the other groups, even though erosions/ulceration was most common. Conclusion. In this study, we found that CE and SBE have similar diagnostic yields and erosions/ulceration was the most common reason for OGIB, followed by mass lesion and angiodysplasias.

Endoscopic treatment of delayed colon perforation: the enteroscopy overtube approach.

BACKGROUND AND STUDY AIMS: Delayed perforation is a rare complication of therapeutic colonoscopy, and it is severe and sometimes lethal. This paper reports on a new minimally invasive method for the treatment of delayed colonic perforation. PATIENTS AND METHODS: Three patients with delayed colonic perforation underwent the therapy, which involved three steps: (1) closure with endoclips and loop, (2) overtube placement, and (3) antibiotic wash through a nasobiliary tube. RESULTS: The procedure was successful in all three patients and no recurrence was observed during 5 - 41 months of follow-up. CONCLUSIONS: Although this study involved only a small number of patients and no control arm, the method involving an overtube appears to be a feasible and effective endoscopic treatment for delayed colonic perforation.

Transoralgastric gastroscopic debridement for peripancreatic abscess: a special case report.

Transoralgastric debridement for pancreatic abscess is one of the successful applications of NOTES in clinical practice. We present a case report as follows: a 71-year-old female was hospitalized due to acute biliary pancreatitis. Three weeks after onset, the secondary abdominal CT showed a peripancreatic abscess. A passageway between the gastric wall and the abscess was made with a high-frequency puncher under the guidance of an ultrasonic gastroscope and then a gastroscope was directly inserted into the abscess, and a large amount of solid necrotic tissue was taken out with foreign body forceps and snare under the direct vision of a gastroscope. Then a 8.5F double-J stent and a nasobiliary drainage tube were inserted. After three times of intra-abdominal abscess debridement and repeated rinsing with an antibiotic solution, abdominal CT revealed the intra-abdominal abscess nearly disappeared and the patient discharged from hospital.

Endoscopic dissection of large endogenous myogenic tumors in the esophagus and stomach is safe and feasible: a report of 42 cases.

OBJECTIVE: Submucosal myogenic tumors, including leiomyoma and stromal tumors, are currently treated primarily by open surgery or laparoscopic excision. The aim of this retrospective study was to evaluate the feasibility of endoscopic dissection (ED) for resecting endogenous esophageal leiomyoma (EL) and gastric stromal tumors (GSTs) with diameters of 5 cm. METHODS: We enrolled 42 patients with endogenous EL and GST who had undergone endoscopic surgery (endoscopic group). These cases were compared retrospectively with 22 patients who had undergone thoracotomy or laparotomy (control group). Endoscopic group (n = 42) received ED for EL and GST resection, including circumferential removal of superficial mucosa of targeted tumor. Control group (n = 22) received thoracotomy or laparotomy for resection of esophageal and gastric myogenic tumors. Main outcome measures were operative time, intraoperative bleeding and perforation, postoperative complications, and hospital stays and costs were compared between groups. RESULTS: Endogenous EL and GST were successfully removed from all patients. Bleeding and perforation occurred in seven and five EL and GST patients, respectively. Bleeding was corrected with argon plasma coagulation (APC). Perforation was endoscopically repaired with clips. Mean operative time was 49 min for endoscopic EL and 55 min for GST resection. No major bleeding or perforation occurred postoperatively. Endoscopic treatment had shorter length of stay and lower hospital costs than conventional procedures. CONCLUSIONS: ED is safe and feasible for resection of endogenous EL and GST in selected cases.

Full-thickness endoscopic resection of nonintracavitary gastric stromal tumors: a novel approach.

BACKGROUND: Until now, the conventional treatment of stromal tumors has been primarily open surgery or laparoscopic excision. The use of combined laparoscopic/endoscopic surgeries has been investigated, but endoscopic therapy alone has been limited to en bloc resection or nucleus removal of intracavitary tumors with diameters<2 cm. Nonintracavitary and intramural gastric stromal tumors preclude the use of endoscopic resection due to the risk of gastric perforation. This study was designed to show the safety and effectiveness of full-thickness endoscopic resection of nonintracavitary stromal tumors based on our direct experience. METHODS: A total of 109 consecutive patients with nonintracavitary gastric stromal tumors<4 cm in diameter underwent surgical treatment; 66 patients received endoscopic surgery and 43 patients received laparoscopic surgery. RESULTS: No significant differences existed between the two groups in terms of demographics and clinical characteristics, and no tumor exceeded 3.5 cm in size. Median operation times (endoscopic group, 53.6 min; laparoscopic group, 139 min) and hospitalization fees of the endoscopic group were significantly lower than those of the laparoscopic group with significant median hospital stays (8 days for endoscopic group; 6 days for laparoscopic group). No intraoperative complications occurred in the laparoscopic group and complete removal of tumors was achieved in the endoscopic group. Postoperative complications occurred in 6 patients of 43 who underwent laparoscopic surgery and 17 patients of 66 who underwent endoscopic surgery, representing a significant difference; the size of the lesion correlated positively with the occurrence of complications. CONCLUSIONS: Endoscopic resection is safe and effective for treating nonintracavitary stromal tumors. The endoscopic natural-cavity technique produced less surgical injury to the patients and preserved the anatomy of intra-abdominal structures. In addition, the endoscopic technique reduced operative times, postoperative bleeding, and costs.