Differentiating Gastrointestinal Stromal Tumors From Leiomyomas of Upper Digestive Tract Using Convolutional Neural Network Model by Endoscopic Ultrasonography.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) and leiomyomas are the most common submucosal tumors of the upper digestive tract, and the diagnosis of the tumors is essential for their treatment and prognosis. However, the ability of endoscopic ultrasonography (EUS) which could correctly identify the tumor types is limited and closely related to the knowledge, operational level, and experience of the endoscopists. Therefore, the convolutional neural network (CNN) is used to assist endoscopists in determining GISTs or leiomyomas with EUS. MATERIALS AND METHODS: A model based on CNN was constructed according to GoogLeNet architecture to distinguish GISTs or leiomyomas. All EUS images collected from this study were randomly sampled and divided into training set (n=411) and testing set (n=103) in a ratio of 4:1. The CNN model was trained by EUS images from the training set, and the testing set was utilized to evaluate the performance of the CNN model. In addition, there were some comparisons between endoscopists and CNN models. RESULTS: It was shown that the sensitivity and specificity in identifying leiomyoma were 95.92%, 94.44%, sensitivity and specificity in identifying GIST were 94.44%, 95.92%, and accuracy in total was 95.15% of the CNN model. It indicates that the diagnostic accuracy of the CNN model is equivalent to skilled endoscopists, or even higher than them. CONCLUSION: While identifying GIST or leiomyoma, the performance of CNN model was robust, which is highlighting its promising role in supporting less-experienced endoscopists and reducing interobserver agreement.

Efficacy of endoscopic ultrasound and endoscopic resection for esophageal schwannoma.

BACKGROUND: Esophageal schwannoma (ES) is a rare submucosal tumor, and its complete and safe resection is a topic that deserves special attention. AIM: This study aimed to investigate the clinical value of endoscopic ultrasound (EUS) in the diagnosis of ES and the clinical efficacy of endoscopic resection for ES. METHODS: The clinical data, endoscopic characteristics, endoscopic treatment, postoperative complications, immunohistochemical results, and follow-up records of patients with ES admitted to the Tianjin Medical University General Hospital from January 2012 to January 2022 were retrospectively analyzed. RESULTS: Under white-light endoscopy, 81.8% (9/11) of lesions were submucosal elevations, covering the normal esophageal epithelium. Two of the lesions with redness and erosive surface. Eight lesions (72.7%) appear on EUS originating from the muscularis propria were homogeneous or inhomogeneous hypoechoic signals. Two lesions were inhomogeneous hyperechoic originating from the submucosa or muscularis propria, respectively. One lesion was homogeneous hypoechoic originating from the submucosa. All lesions had no blood flow signals, cystic changes, or calcification, and were completely removed by submucosal tunnel endoscopic resection (STER) or endoscopic submucosal dissection (ESD). All patients did not experience serious adverse events as well as recurrence, metastasis, or cicatricial esophageal stenosis during the follow-up period. CONCLUSION: ES is a rare submucosal lesion, which endoscopic characteristics are difficult to distinguish from other esophageal submucosal tumors. Endoscopic resection can provide a minimally invasive and alternative treatment for ES.

Endoscopic resection in the treatment of intramural esophageal bronchogenic cysts: A retrospective analysis of 17 cases.

BACKGROUND: Intramural esophageal bronchogenic cysts (EBCs) are rare congenital malformations. Differences in reports on the clinical features of intramural EBCs and some controversies about the treatment strategy for intramural EBCs exist. OBJECTIVES: To investigate the clinical characteristics of intramural EBCs and evaluate the safety and efficacy of endoscopic resection. METHODS: The clinical and endoscopic features, endoscopic resection treatment, postoperative adverse events, and follow-up results of 17 patients with intramural EBCs were retrospectively studied. RESULTS: Intramural EBCs exhibited male predominance with a male/female ratio of 58.8% (10/7) and were predominantly found in the distal esophagus. Approximately 94.1% of patients presented with gastrointestinal symptoms. All lesions were protruding masses covered by intact mucosal epithelium. The morphologies of intramural EBCs were diverse under white light endoscopy. On endoscopic ultrasonography, intramural EBCs presented as homogeneous or inhomogeneous hypoechoic or anechoic lesions. Eleven lesions originated from the muscularis propria, which underwent submucosal tunnel endoscopic resection (STER), and six lesions were from the submucosa, which underwent endoscopic submucosal dissection (ESD). Approximately 88.2% of patients underwent complete endoscopic resection. No serious pneumothorax, bleeding, pleural effusion, esophagotracheal fistula, or other adverse events occurred in all patients after endoscopic resection, and no cyst recurrence, metastasis, or esophageal scar stenosis was observed during the follow-up period. CONCLUSIONS: Intramural EBCs can be treated by digestive endoscopic surgery. STER and ESD are safe, effective, and minimally invasive resection methods.

Effect of esophageal muscle fibrosis on prognosis of per-oral endoscopic myotomy (POEM) in achalasia patients.

BACKGROUND AND AIMS: Although esophageal smooth muscle fibrosis of achalasia (AC) patients has been described, the role and mechanism remain unclear. The aim of this study was to evaluate the fibrosis in the distal esophageal muscle in patients with AC and explore its relationship with prognosis of per-oral endoscopic myotomy (POEM). METHODS: Lower esophageal sphincter (LES) muscle from forty patients undergoing POEM for AC were obtained at the time of surgery. Control specimens consisted of similar muscle taken from distal esophagectomy for gastric tumors. The muscle fibrosis were assessed by Masson staining and confirmed by immunohistochemistry for collagen I and III. The total number of eosinophil within the myenteric propria were counted. In addition, clinical data were obtained through electronic medical records. Statistical comparison between groups were made. RESULTS: A significantly higher proportion of fibrosis in AC as compared with controls (P = 0.000). Eosinophil count, TGF-ß1, collagen I, and III were higher than those of control (P = 0.000, P = 0.001, P = 0.011, and P = 0.002, respectively). TGF-ß1, collagen I, and III were positively correlated with eosinophil count (all P < 0.05). Furthermore, the proportion of severe LES fibrosis in patients who failed to respond to POEM two years after operation was higher than that in responders (P = 0.028). And, Eckardt score two years after POEM was also positively correlated with degree of fibrosis-related cytokines (all P < 0.05). CONCLUSION: Smooth muscle fibrosis was prominent in lower part of esophagus of AC and positively correlated with severity of symptoms two years after POEM. The fibrosis might be relevant to eosinophil infiltration and TGF-ß1. Further studies are required to more clearly delineate the mechanism of muscle fibrosis and its correlation with prognosis of therapy for this idiopathic disease.

Role of endoscopic ultrasound and endoscopic resection in the diagnosis and treatment of esophageal granular cell tumors.

BACKGROUND AND AIM: Diagnosis and complete resection of esophageal granular cell tumors (GCTs) is an area of concern. However, articles on endoscopic ultrasound (EUS) and endoscopic resection of esophageal granular cell tumors are few. To evaluate the role of endoscopic ultrasound and endoscopic resection in the diagnosis and treatment of esophageal granular cell tumors. METHODS: A retrospective analysis of 15 patients with esophageal granular cell tumors who underwent endoscopic ultrasound examination and endoscopic resection in our hospital was conducted. The clinical data, endoscopic ultrasound images, endoscopic treatment, pathological characteristics, postoperative complications and follow-up status of all patients were evaluated. Ten board-certified endoscopists independently evaluated the white light endoscopic images of the 15 patients (Test 1) and the endoscopic ultrasound images together with white light endoscopic images of the same patient set (Test 2). RESULT: Female patients accounted for 53.4% of the participants. The average age at the time of diagnosis was 49.13 ± 9.31 years old. Ten lesions (66.67%) showed hypoechoic signal, four lesions (26.67%) showed hyperechoic signal and one lesion showed medium signal. The diagnostic accuracy was significantly higher with Test 2(65.3% vs. 92.0%, p < .001). Complete endoscopic resection was performed in all the patients. No complications occurred in any of the patients. No esophageal stenosis, recurrence, or metastases was found in all patients during the follow-up period. CONCLUSION: The endoscopic ultrasound images of esophageal granular cell tumors have certain characteristics that help diagnose esophageal granular cell tumors. Endoscopic resection of esophageal granular cell tumors is an effective, safe and feasible treatment method.

20-Year Trends in Detection Rates of Cardia Cancer via Endoscopic Surveillance in Tianjin, China: A Hospital-Based Study.

Background: To analyze the time trends in cardia cancer detection rates using endoscopic surveillance from 1999 to 2019 in a high-volume Chinese hospital. Methods: In this retrospective, single-center study, data were collected from the Endoscopy Center of the Department of Gastroenterology, Tianjin Medical University General Hospital, from 1999 to 2019. Cases of cardia cancer (n = 1567) were extracted from a database of patients who underwent endoscopy. Clinical and epidemiological characteristics of patients with cardia cancer were analyzed, including sex, age, and proportion of early gastric cancer and degree of tumor differentiation. The joinpoint regression method was used to identify change points in incidence trends. Annual percent change (APC) values, with 95% confidence intervals (CI), were calculated for time periods before and after change points. Results: Of the 343942 patients who underwent endoscopy during 1999-2009, 1567 (4.6%) were identified with cardia cancer. The overall cardia adenocarcinoma detection rate decreased significantly from 1999 to 2004 (APC = -37.3, 95% CI: -20.9, -6.4), followed by a relatively slower decline rate from 2004 to 2019 (APC = -7.7, 95% CI: -4.4, -7.6). The crude rate of detection of early cardia cancer could not be determined by joinpoint analysis. Rates of detection reduced significantly in patients aged 60-69 and 70-79 years (APC = -8.3, 95% CI: -9.8, -6.8 and APC = -7.3, 95% CI: -8.8, -5.8, respectively). The detection rate in males decreased rapidly from 1999 to 2004 (APC = -35.9, 95% CI: -18.2, 5.6, P < 0.05), while the decline rate was relatively slow from 2005 to 2019 (APC = -6.9, 95% CI: -3.4, -6.1, P < 0.05). Among females, the detection rates also decreased from 1999 to 2004 (APC = -21.2, 95% CI: -28.1, -13.7), but remained stable from 2007 to 2019 (APC = -3.8, 95% CI: -7.9, -0.5). Detection of poorly differentiated cardia cancer also declined from 2009 to 2019 (APC = -12.8, 95% CI: -15.3, -10.0). Conclusions: The detection rate of cardia cancer among gastric cancers has been stable from 2008 to 2019. The trend of detection rate of early cardia cancer showed no significant statistical meaning; hence, it remains necessary to carefully observe the cardia area during endoscopy examination.

Peroral endoscopic myotomy for the treatment of achalasia after failed pneumatic dilation.

BACKGROUND AND AIMS: POEM is a rescue endoscopic therapy for patients who had previously failed surgical or endoscopic treatment. However, data regarding its effectiveness after failed pneumatic dilation (PD) and its long-term effects are limited. We aimed to retrospectively investigate the long-term outcomes in patients who had undergone POEM after failed PD. METHODS: Data from 66 achalasia patients with a 2-year follow-up period were analyzed. Intraprocedural events were compared between the first POEM group (patients without prior-endoscopic intervention) and prior PD group (patients who had pre-POEM PD). Symptom evaluation, HRM and 24 h-pH DeMeester scores between the two groups were performed at 2 years after the POEM procedure. Muscularis externa samples were obtained from the lower esophagus using POEM to assess the muscle fibrosis with Azan-Mallory staining. RESULTS: POEM was successfully performed for all achalasia patients. During the 2-year follow-up period, the success rate of POEM was 96.15% (25/26) for patients with prior PD and 95% (38/40) with primary POEM. For patients with type II achalasia and who underwent prior PD, the post-procedure DeMeester score was higher compared to patients who underwent POEM only (P < 0.05). A larger number of patients who underwent primary POEM (27.50%, 11/40) complained of mild heartburn compared to patients who underwent POEM after PD (7.69%, 2/26) (P < 0.05). With regards to fibrosis, the majority of patients who underwent POEM only were classified as F-1 (45.00%, 18/40), while the majority of patients who underwent prior PD were classified as F-2 (42.3%, 11/26). The degree of fibrosis was significantly different between the two groups (P < 0.05). Both surgical time and prior PD were correlated with the degree of fibrosis (P < 0.05). CONCLUSIONS: Despite the technical challenges, pre-POEM endoscopic treatment does not impact the safety and efficacy of POEM in achalasia patients. Longer follow-up studies using larger cohorts are needed to determine long-term outcomes and complications of POEM.

An Animal Study of Implantation of an Esophageal Pacemaker Based on Per-Oral Endoscopic Myotomy Approach for Alleviation of Esophageal Peristalsis Disorders.

BACKGROUND To restore esophageal peristalsis of achalasia patients by sequenced electric stimulation, an appropriate method must be established to implant the electrodes and pacemaker safely and effectively. We combined POEM (per-oral endoscopic myotomy) and abdominal wall puncture in pigs in order to explore a feasible procedure for the implantation. MATERIAL AND METHODS Five healthy male pigs were used in the present study with the permission of the Ethics Committee of Tianjin Medical University General Hospital. The electrodes were implanted in esophageal submucosal tunnel by POEM with the end of the electrode deposited in the abdominal cavity using NOTES technique. A pacemaker was then positioned under the skin of the abdomen. Finally, the electrodes were connected with the pacemaker with the help of endoscopy in the abdominal cavity. Esophageal peristalsis of these pigs after implantation was monitored for esophageal intraluminal pressure changes using electronic gastroscopy and a high-resolution manometry (HRM). The observation lasted for 6 h. RESULTS The procedure was effective to implant the electrode and the pacemaker using POEM and NOTES techniques. The connection of the 2 devices was also successful. Esophageal intraluminal pressure changes after electrical stimulation were recorded using HRM. Vital signs of the pigs were stable during the 6-h follow-up. CONCLUSIONS From this small-sample, short follow-up animal study, it was found that the implantation of esophageal electrodes and pacemaker based on POEM and NOTES is feasible, safe, and effective. Nevertheless, there is urgent need for long-term follow-up to confirm or disprove the safety of the procedure.

Submucosal tunneling endoscopic resection of large submucosal tumors originating from the muscularis propria layer in the esophagus and gastric cardia.

AIMS: The aim of this study was to evaluate the short-term complications of submucosal tunneling endoscopic resection (STER) for large submucosal tumors (SMTs) originating from the muscularis propria (MP) layer in the esophagus and gastric cardia. METHODS: We performed 286 cases of STER from September 2012 to December 2017. The clinical data of patients with SMTs originating from the MP layer of 3.0-7.0 cm, who underwent STER procedure at the endoscopy center of Tianjin Medical University General Hospital, were collected retrospectively. Epidemiological data, tumor location, tumor size, procedure-related parameters, complications, and follow-up were included. RESULTS: A total of 27 (9.4 % [27/286]) patients were large-size SMTs, with a mean age of 51.9 ±â€Š9.4 years. The male/female ratio was 19:8. Of the 27 SMTs, 23 were located in the esophagus and 4 in the gastric cardia. The mean tumor size was 4.0 ± 1.1 cm. The en bloc resection rate was 85.2 % (23/27), and the complete resection rate was 100 % (27/27). Intra-operative perforation occurred in 2 patients (7.4 %) and post-operative perforation occurred in 2 patients (7.4 %). No other complications were observed. The average cost of the procedure was $3357.99 ± $1171.60 per inpatient stay (including both the procedure and an additional inpatient stay). The mean follow-up time was 15 ±â€Š10.1 months. No recurrence and metastasis occurred during the follow-up period. CONCLUSIONS: There is low risk of STER for the large-sized SMTs in the esophagus and gastric cardia, and the most common complication occurred during or after the procedure is perforation.

Efficacy and safety of endoscopic submucosal dissection for gastrointestinal neuroendocrine tumors: a 10-year data analysis of Northern China.

Objective: Endoscopy is the main method to treat gastrointestinal neuroendocrine tumors (GI-NETs), but the specific indications are still controversial. We aim to investigate the clinical outcomes of GI-NETs patients who experienced endoscopic submucosal dissection (ESD). Methods: We retrospectively reviewed the clinical features and prognosis of 65 GI-NETs patients who underwent ESD between 2008 and 2018. Results: A total of 65 patients diagnosed with GI-NETs pathologically, bearing 75 lesions, were found by endoscopy incidentally for other symptoms. The locations of these lesions were stomach (n = 24), duodenal bulb (n = 4) and rectum (n = 47). The diameter of 75 tumors were as follows: size ≤ 1 cm (78.7%), 1 cm < size ≤ 2 cm (17.3%), 2 cm < size ≤ 3.5 cm (4.0%). Endoscopic ultrasonography (EUS) suggested that 72 lesions were confined to submucosa and 3 lesions invaded into muscularis propria. The rates of en bloc resection and complete resection were all 100% and the rates of intraoperative bleeding and perforation were 2.7% and 1.3%, respectively. None of the 65 patients had lymph nodes and distant metastasis during the period of study. Conclusion: For GI-NETs without lymph nodes and distant metastases, the lesion confined to submucosa with the diameter ≤1 cm is absolute indication of ESD. For rectal neuroendocrine tumors limited in submucosa with the diameter between 1 and 2 cm, and Type 1 gastric neuroendocrine tumors predicted to be T2, ESD should be prioritized to preserve gastrointestinal volume and function at initial treatment.

Peroral endoscopic myotomy versus pneumatic dilation - result from a retrospective study with 1-year follow-up.

BACKGROUND AND AIMS: On the basis of lesser rates of major adverse events and a short-term efficacy as Heller's myotomy, there is a growing enthusiasm in favor of peroral endoscopic myotomy (POEM), whereas study comparing POEM and pneumatic dilatation (PD) is quite rare. The aim of this study was to evaluate the efficacy of POEM and PD in Chinese achalasia patients in a retrospectively designed study. METHODS: Patients with achalasia, who underwent either PD (n = 26) or POEM (n = 40) were retrospectively recruited from September 2010 through March 2016 at a single tertiary center. During the 1-year follow-up, clinical outcome and functional data of lower esophageal sphincter (LES) were recruited. Clinical symptoms were assessed by use of the Eckardt score. The primary outcome was therapeutic success (Eckardt score ≤ 3). Functional data of LES (4-second integrated relaxation pressure [4s-IRP], LES relax rate, and LESP) at baseline and 1 month after treatment were also evaluated. Data was analyzed by SPSS 13.0 version using a significance level of p < 0.05. RESULTS: The success rates were 24/26 (92.31 %), 25/26 (96.15 %), and 24/26 (92.31 %), respectively, with POEM, as compared with 35/40 (87.50 %), 29/40 (72.50 %), and 23/40 (57.50 %), respectively, with PD, 1 month, 3 months, and 1 year after treatment. Statistically significant difference was observed between the 2 therapies (at 3 months, Fisher's exact test, p = 0.01; at 1 year, Fisher's exact test, p < 0.0001). Compared with PD, the Eckardt score was lower with POEM 1 month, 3 months, and 1 year after treatment. More patients in POEM group reported gastroesophageal reflux symptoms (after 3 months 7/26 (26.92 %) vs. 2/40 (5.00 %), Fisher's exact test, p = 0.01; after 1 year 6/26 (19.23 %) vs. 1/35 (2.86 %), Fisher's exact test, p = 0.02). The postoperative 4s-IRP and LESP were both lower with POEM than with PD, respectively. Type I achalasia had a better response with POEM than with PD. CONCLUSION: In this retrospective analysis with 1-year follow-up, POEM presents with a higher success rate and more reflux symptoms compared with PD. Change on LES function after treatment may explain the outcome in part. Type I achalasia may respond better to therapies compared with type II.

Is It Necessary to Intubate the Cecum to Examine the Whole Colorectum During Endoscopic Polypectomy?

BACKGROUND The official guidelines are unclear about whether endoscopic polypectomy should intubate the whole cecum or just intubate the location of the endoscopy inspection. Therefore, the objective of this study was to provide a new perspective of assisting endoscopists make better decisions and decrease the missing detection rate in clinical practice. MATERIAL AND METHODS We retrospectively reviewed records of 8923 patients who underwent endoscopic polypectomy, and 394 participants were included after screening by inclusion and exclusion criteria. We collected and analyzed data on the size, shape, and location of polyps and the clinical experience level of endoscopists in this retrospective study. RESULTS Among the 394 cases, 152 (38.6%) had additional lesions detected through the second endoscopic polypectomy after the first colonoscopy was performed, showing statistically significant differences between the missing group and non-missing group on actual polys (P<0.05). No significant differences were detected between the 2 groups (P>0.05) in age, sex, withdrawal time, and examination period. Regarding the location, 50.4% of the missing lesions were found on the relatively proximal colon of the detected polyps in the first colonoscopy. In addition, the level of experience of endoscopists was significantly different between the missing group and the non-missing group (P<0.05). CONCLUSIONS The characteristics of polyps and the level of endoscopist experience play important roles in the detection of polyps in the colorectum. Moreover, it may be necessary to intubate the cecum to examine the whole colorectum during endoscopic polypectomy.

External validation and improvement of LiFe score as a prediction tool in critically ill cirrhosis patients.

AIM: The LiFe (liver, injury, failure, evaluation) score, calculated according to arterial lactate, total bilirubin, and international normalized ratio (INR), is a novel score for risk prediction in intensive care unit (ICU) patients with cirrhosis. The present study aimed to externally validate and optimize the LiFe score for predicting outcomes in critically ill cirrhosis patients. METHODS: The study used the single-center database Medical Information Mart for Intensive Care-III (MIMIC-III) for analysis. A total of 536 critically ill cirrhosis patients from the MIMIC-III database were analyzed. Routine clinical and laboratory variables were included to compare survivors with non-survivors. The LiFe score was then regraded into three groups to calculate the optimal cut-off values. RESULTS: In-ICU mortality occurred in 169 (31.5%) of the patients. Survivor and non-survivor cohorts were similar in age, gender, and etiology of cirrhosis. Multivariate analyses of in-ICU mortality identified four independent variables: total bilirubin, creatinine, INR, and arterial lactate. An external validation of the LiFe score showed good accuracy for predicting in-ICU mortality with an area under the receiver operating characteristic curve of 0.708. In addition, a significant positive correlation exists between LiFe score and acute-on-chronic liver failure grade (r = 0.393, P < 0.001). A log-rank test comparing the strata of simplified LiFe scores found that in-ICU mortality rates were 16.8%, 27.7%, and 51.7%, respectively, among patients in the three simplified risk categories. CONCLUSIONS: The LiFe score, based on laboratory tests, can be useful as a preliminary and convenient scoring tool in a broad cohort of critically ill cirrhosis patients. Simplified risk categories to stratify patients into three groups improves its feasibility and generalizability for clinical application.

Occurrence of metachronous multiple primary cancers occurred in different parts of the stomach with 2 pathologic features: A case report.

RATIONALE: With the increasing survival rate of gastric cancer, more multiple primary cancers (MPC) have been reported. However, few cases involve metachronous multiple primary cancers which both occurred in the stomach. PATIENT CONCERNS: An 83-year-old Chinese male had been diagnosed with gastric cardia cancer and underwent proximal gastrectomy. The pathological result was gastric adenocarcinoma. 13 years later the patient's gastroscope result deteriorated. The biopsy of the antrum revealed dysplasia with doubtful focal cancerization. DIAGNOSES: Metachronous multiple primary cancers in the stomach. INTERVENTIONS: Endoscopic submucosal dissection (ESD) was performed. The pathological result showed an intra-mucosal signet-ring carcinoma. OUTCOMES: After treatment, the patient is alive with good condition until now. LESSONS: This is an unusual case of MPC with different pathological features in different parts of the same organ in an interval of more than ten years and undergoing different operations.

Is integrated relaxation pressure a promising predictor of effectiveness of peroral endoscopic myotomy for achalasia?

BACKGROUND: Peroral endoscopic myotomy (POEM), first introduced in 2010, appears to be an effective therapy with few complications. This study aimed to find an optimal predictor of POEM outcome in achalasia. METHODS: We retrospectively assessed 89 patients diagnosed with achalasia who underwent POEM in General Hospital of Tianjin Medical University, from September 2012 to March 2015. Associations of Eckardt score with symptom duration, lower esophageal resting pressure, 4-second integrated relaxation pressure (4s-IRP), and maximum esophageal diameter were assessed before POEM. The most relevant data were progressively grouped to compare symptom improvement after POEM in 85 patients at 1 year follow-up. RESULTS: The most significant correlation was found between 4s-IRP and Eckardt score (p < 0.01). The 85 achalasia patients (1-year follow-up after POEM) were divided into 3 groups according to 4s-IRP values; patients with mean 4s-IRP of 25 - 34 mmHg exhibited significantly greater improvement of clinical symptoms compared with the remaining 2 groups (p < 0.05). No significant postoperative difference was noted between types I and II in all patients according to Chicago classification criteria. The 40 patients with 4s-IRP of 25 - 34 mmHg were further divided into 2 subgroups; the 28 patients with type II achalasia responded better to POEM than the 12 with type I disease (p < 0.05). CONCLUSIONS: 4s-IRP, together with achalasia subtypes, may predict treatment outcome after POEM. Patients with type II achalasia and 4s-IRP of 25 - 34 mmHg may experience more satisfactory remission after POEM.

Endoscopic submucosal dissection for large colorectal epithelial neoplasms: A single center experience in north China.

Colorectal endoscopic submucosal dissection (ESD) is a technically difficult procedure with a higher risk of complications, especially for large colorectal epithelial neoplasms. This study aimed to report our experience and clinical outcomes, and to estimate the factors associated with incomplete resection and complications.One hundred forty one colorectal epithelial neoplasms in 130 consecutive patients treated by ESD at the endoscopy center of Tianjin Medical University General Hospital from January 2013 to January 2016 were included. Factors associated with the incomplete resection and perforation were evaluated.The mean colorectal epithelial neoplasm size was 26.5 ±â€Š9.5 (15.0-60.0) mm, the mean procedure time of colorectal ESD was 76.1 ±â€Š48.7 (36.5-195.0) minutes. The en bloc resection rate, the en bloc R0 resection rate, and the curative resection rate, were 93.6% (132/141), 91.5% (129/141), and 88.7% (125/141), respectively. Perforation during colorectal ESD occurred in 7 patients (4.9%), postoperative bleeding occurred in 4 patients (2.8%). There was no recurrence occurred in all patients during follow periods of 13.2 ±â€Š8.6 (6.0-36.0) month. Submucosal fibrosis was the only independent factor related to both incomplete resection (odds ratio [OR] 12.425; 95% confidence interval [CI] 2.501-61.734; P = .002) and perforation (OR 10.646; 95%CI 1.188-95.421; P = .035) of colorectal ESD.Colorectal ESD is a safe and effective technique for en bloc resection of large colorectal epithelial neoplasms. Submucosal fibrosis was independently related to incomplete resection and perforation.

Analysis of the learning curve for peroral endoscopic myotomy for esophageal achalasia: Single-center, two-operator experience.

BACKGROUND AND AIM: Peroral endoscopic myotomy (POEM) has emerged as an advanced technique for the treatment of achalasia, and defining the learning curve is mandatory. METHODS: From August 2011 to June 2014, two operators in our institution (A&B) carried out POEM on 35 and 33 consecutive patients, respectively. Moving average and cumulative sum (CUSUM) methods were used to analyze the POEM learning curve for corrected operative time (cOT), referring to duration of per centimeter myotomy. Additionally, perioperative outcomes were compared among distinct learning curve phases. RESULTS: Using the moving average method, cOT reached a plateau at the 29th case and at the 24th case for operators A and B, respectively. CUSUM analysis identified three phases: initial learning period (Phase 1), efficiency period (Phase 2) and mastery period (Phase 3). The relatively smooth state in the CUSUM graph occurred at the 26th case and at the 24th case for operators A and B, respectively. Mean cOT of distinct phases for operator A were 8.32, 5.20 and 3.97 min, whereas they were 5.99, 3.06 and 3.75 min for operator B, respectively. Eckardt score and lower esophageal sphincter pressure significantly decreased during the 1-year follow-up period. Data were comparable regarding patient characteristics and perioperative outcomes. CONCLUSION: This single-center study demonstrated that expert endoscopists with experience in esophageal endoscopic submucosal dissection reached a plateau in learning of POEM after approximately 25 cases.

Hemostatic effect of topical hemocoagulase spray in digestive endoscopy.

AIM: To evaluate the hemostatic effect of topical hemocoagulase spray in digestive endoscopy. METHODS: Eighty-nine patients who developed oozing bleeding during endoscopic treatment from September 2014 to October 2014 at Center for Digestive Endoscopy, Tianjin Medical University General Hospital were randomly divided into either a study group (n = 39) or a control group (n = 50). The study group was given topical hemocoagulase spray intraoperatively, while the control group was given traditional 8% norepinephrine spray. Hemostatic efficacy was compared between the two groups. Bleeding site, wound cleanliness and perforation were recorded, and the rates of perforation and late bleeding were compared. RESULTS: Successful hemostasis was achieved in 39 (100%) patients of the study group and in 47 (94.0%) patients of the control group, and there was no significant difference in the rate of successful hemostasis between the two groups. Compared with the control group, after topical hemocoagulase spray in the study group, the surgical field was clearer, the bleeding site was more easily identified, and the wound was cleaner. There was no significant difference in the rate of perforation between the study and control groups (16.7% vs 35.0%, P = 0.477), but the rates of late bleeding (0% vs 15.8%, P = 0.048) and overall complications (P = 0.032) were significantly lower in the study group. CONCLUSION: Topical hemocoagulase spray has a definite hemostatic effect for oozing bleeding in digestive endoscopy, and this method is convenient, safe, and reliable. It is expected to become a new method for endoscopic hemostasis.

Ligation-Assisted Endoscopic Enucleation for the Resection of Gastrointestinal Tumors Originating from the Muscularis Propria: Analysis of Efficacy and Facility.

BACKGROUND: Gastrointestinal tumors originating from the muscularis propria are believed to have the potential to progress to malignant tumors. The efficacy of 'pre-management' with elastic band or endoloop assistant ligation after initial submucosal dissection in endoscopic enucleation procedure of these tumors was investigated and evaluated. METHODS: The study included 21 patients with small gastric stromal tumors arising in the gastric muscularis propria as determined by endoscopy (endoscopic ultrasonography). A standard endoscope with a transparent cap attached to the tip was used. The cap was placed over the lesion, after incision of the surrounding tissue, maximum sustained suction was applied. Then the elastic band or endoloop was released around the base. Circumference resection was performed with clips strengthening the defect closure. RESULTS: The 22 gastrointestinal stromal tumors sloughed completely. The mean time required for the full-thickness resection was 48 min. Minor perforation occurred with metal clips closing the defect of the gastric wall. Follow-up ranged from 13 to 42 months, during which time no recurrence was observed postoperatively. CONCLUSIONS: The band or endoloop assistant endoscopic ligation technique is effective for the enucleation of deep gastric tumors. It may help avoiding disturbance the abdominal cavity hemostasis in traditional full-thickness enucleation procedure.