Is it enough to observe less than 2 cm sized gastric SET?

BACKGROUND AND AIMS: The recent surge in demand for screening endoscopy has led to an increased detection of gastric subepithelial tumors (SETs). According to current guideline, SETs less than 2 cm in size are recommended for periodic surveillance. In light of recent advancement in therapeutic endoscopy in resection of small SET, we analyzed the histopathological features and the effectiveness of endoscopic resection for these small SETs. METHODS: Retrospectively study was performed on 74 patients who underwent endoscopic resection of gastric small (≤ 2 cm) upper gastrointestinal tract SETs. The outcomes including histopathology and en bloc resection were analyzed. RESULTS: The mean SET size was 11.69 ± 5.11 mm. The mean procedure time was 81.26 ± 42.53 min. Of the 74 patients, 28 patients had leiomyomas, 26 had gastrointestinal stromal tumors (GISTs), 14 had ectopic pancreas, 4 had lipomas, and 2 had neuroendocrine tumors. Among those with GIST, two patients exhibited high-risk histology. All patients underwent successful and uneventful endoscopy. CONCLUSIONS: Endoscopic resection can be recommended even for the small gastric SETs. In our study, we found that SETs with a size of less than 2 cm have significant proportion of GISTs which harbor malignant transformation potential.

A modified endoscopic full thickness resection for gastric subepithelial tumors from muscularis propria layer: Novel method.

BACKGROUND AND AIM: The removal of subepithelial tumors (SETs) is challenging, particularly in tumors originating from the muscularis propria (MP) in the upper gastrointestinal (GI) tract, owing to the high risk of perforation. We developed mechanical spray lumpectomy (MSL), which is a novel method to safely and easily remove the tumor. This study aimed to evaluate the feasibility and safety of MSL as a novel endoscopic treatment for gastric subepithelial lesions. METHODS: We performed MSL in a total of 13 patients with upper GI SETs originating from the MP layer. First, mucosectomy was performed using a conventional snare. Repeated injections were performed towards the subserosal layer. After injection, the lesion was mechanically pushed to separate the MP layer using an endoscopic cap. Finally, the mucosa, submucosa, and MP layer with SETs were completely dissected using the spray coagulation mode, and the remaining defect was closed with clipping. RESULTS: All tumors were completely resected. The mean procedure time was 84.38 ± 41.73 min. There were four leiomyomas, six GI stromal tumors, one mucosa-associated lymphoid tissue lymphoma, and two ectopic pancreases. Although small perforation occurred in only one case, the defect was successfully closed using hemostatic clipping. Moreover, no serious complications related to MSL were encountered during or after the procedure. No residual lesion or recurrence was observed during the follow-up period. CONCLUSIONS: Mechanical spray lumpectomy can be a novel method that provides a safe and minimally invasive endoscopic treatment for upper GI SETs originating from the MP layer.

Linear-shaped gastroduodenostomy (LSGD): safe and feasible technique of intracorporeal Billroth I anastomosis.

BACKGROUND: Although delta-shaped gastroduodenostomy (DSGD) is used increasingly as an intracorporeal Billroth I anastomosis after distal gastrectomy, worries about anatomical distortion always exist in twisting stomach and making an oblique incision on duodenum. We developed a new method of intracorporeal gastroduodenostomy, the linear-shaped gastroduodenostomy (LSGD), in which anastomosis is done using endoscopic linear staplers only without any complicated rotation. In this report, we introduced LSGD and compared its short-term and long-term outcomes with DSGD. METHODS: We analyzed 261 consecutive gastric cancer patients who underwent the intracorporeal gastroduodenostomy between January 2009 and May 2014 (LSGD: 190, DSGD: 71), retrospectively. All of them underwent a laparoscopic or robotic distal gastrectomy with regional lymph node dissection. Early surgical outcomes such as operation time, postoperative complications, days until soft diet began, length of hospital stay, and endoscopic findings in postoperative 6 and 12 months were evaluated. RESULTS: Although the proportion of robotic approach and D2 lymphadenectomy were significantly higher in LSGD group, the rates for overall complications (13.2 % [LSGD] vs. 9.9 % [DSGD], p = 0.470) and major complications (5.8 vs. 5.6 %, p = 1.0) were similar between two groups. There were no differences in anastomotic bleeding (1.1 vs. 1.4 %, p = 1.0), stenosis (3.2 vs. 2.8 %, p = 1.0), and leakage (0.5 vs. 0.0 %, p = 1.0). Endoscopy performed 6 months postoperatively showed that residual food (p = 0.022), gastritis (p = 0.018), and bile reflux (42.0 vs. 63.2 %, p = 0.003) were significantly decreased in LSGD and there were no significant differences in postoperative 12 months. CONCLUSION: LSGD is an innovative reconstruction technique with comparable short-term outcomes to DSGD. In addition, reduced residual food, gastritis, and bile reflux were seen in LSGD.

Upconverting Nanoparticle-based Enhanced Luminescence Lateral-Flow Assay for Urinary Biomarker Monitoring.

Development of efficient portable sensors for accurately detecting biomarkers is crucial for early disease diagnosis, yet remains a significant challenge. To address this need, we introduce the enhanced luminescence lateral-flow assay, which leverages highly luminescent upconverting nanoparticles (UCNPs) alongside a portable reader and a smartphone app. The sensor's efficiency and versatility were shown for kidney health monitoring as a proof of concept. We engineered Er3+- and Tm3+-doped UCNPs coated with multiple layers, including an undoped inert matrix shell, a mesoporous silica shell, and an outer layer of gold (UCNP@mSiO2@Au). These coatings synergistically enhance emission by over 40-fold and facilitate biomolecule conjugation, rendering UCNP@mSiO2@Au easy to use and suitable for a broad range of bioapplications. Employing these optimized nanoparticles in lateral-flow assays, we successfully detected two acute kidney injury-related biomarkers─kidney injury molecule-1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL)─in urine samples. Using our sensor platform, KIM-1 and NGAL can be accurately detected and quantified within the range of 0.1 to 20 ng/mL, boasting impressively low limits of detection at 0.28 and 0.23 ng/mL, respectively. Validating our approach, we analyzed clinical urine samples, achieving biomarker concentrations that closely correlated with results obtained via ELISA. Importantly, our system enables biomarker quantification in less than 15 min, underscoring the performance of our novel UCNP-based approach and its potential as reliable, rapid, and user-friendly diagnostics.

A practical approach for small bowel bleeding.

Gastrointestinal (GI) bleeding is one of the most common conditions among patients visiting emergency departments in Korea. GI bleeding is divided into upper and lower GI bleeding, according to the bleeding site. GI bleeding is also divided into overt and occult GI bleeding based on bleeding characteristics. In addition, obscure GI bleeding refers to recurrent or persistent GI bleeding from a source that cannot be identified after esophagogastroduodenoscopy or colonoscopy. The small intestine is the largest part of the alimentary tract. It extends from the pylorus to the cecum. The small intestine is difficult to access owing to its long length. Moreover, it is not fixed to the abdominal cavity. When hemorrhage occurs in the small intestine, the source cannot be found in many cases because of the characteristics of the small intestine. In practice, small-intestinal bleeding accounts for most of the obscure GI bleeding. Therefore, in this review, we introduce and describe systemic approaches and examination methods, including video capsule endoscopy and balloon enteroscopy, that can be performed in patients with suspected small bowel bleeding in clinical practice.

Normalizing the Optical Signal Enables Robust Assays with Lateral Flow Biosensors.

Lateral flow assays (LFAs) are widely adopted for fast, on-site molecular diagnostics. Obtaining high-precision assay results, however, remains challenging and often requires a dedicated optical setup to control the imaging environment. Here, we describe quick light normalization exam (qLiNE) that transforms ubiquitous smartphones into a robust LFA reader. qLiNE used a reference card, printed with geometric patterns and color standards, for real-time optical calibration: a photo of an LFA test strip was taken along with the card, and the image was processed using a smartphone app to correct shape distortion, illumination brightness, and color imbalances. This approach yielded consistent optical signal, enabling quantitative molecular analyses under different illumination conditions. We adapted qLiNE to detect cortisol, a known stress hormone, in saliva samples at point-of-use settings. The assay was fast (15 min) and sensitive (detection limit, 0.16 ng/mL). The serial qLiNE assay detected diurnal cycles of cortisol levels as well as stress-induced cortisol increase.

Characterization and modulation of surface charges to enhance extracellular vesicle isolation in plasma.

Extracellular vesicles (EVs) carry information inherited from parental cells, having significant potential for disease diagnosis. In blood, however, EVs are outnumbered >104-fold by low density lipoproteins (LDLs), yet similar in size and density. These fundamental disadvantages often cause LDL spillover into EV isolates, thus confounding assay results. We hypothesized that EVs can be further separated from LDLs based on electric charge: EVs and LDLs have different lipid composition, which can lead to differential surface charge densities. To test this hypothesis, we modeled and quantified the surface charge of EVs and LDLs, and used the information to optimally separate EVs from LDLs via ion-exchange chromatography. Methods: We built an enhanced dual-mode chromatography (eDMC) device which performed i) size-exclusion to remove particles smaller than EVs and LDLs and ii) cation-exchange in an acidic elution to retain LDLs longer than EVs. The performance of the eDMC, in comparison to size-exclusion only, was evaluated by analyzing the yield and purity of the isolated EVs. Results: By measuring and modeling zeta potentials at different buffer pH, we estimated surface charge densities of EVs (-6.2 mC/m2) and LDLs (-3.6 mC/m2), revealing that EVs are more negatively charged than LDLs. Furthermore, the charge difference between EVs and LDLs was maximal at a weak acidic condition (pH = 6.4). By applying these findings, we optimized eDMC operation to enrich EVs directly from plasma, depleting >99.8% of LPPs within 30 min. Minimizing LDL contamination improved analytical signals in EV molecular assays, including single vesicle imaging, bulk protein measurements, and mRNA detection. Conclusions: These developments will promote the translational value of the dual-mode separation - a fast, equipment-free, and non-biased way for EV isolation from plasma samples.

Zwitterionic Polymer Electroplating Facilitates the Preparation of Electrode Surfaces for Biosensing.

Surface chemistry critically affects the diagnostic performance of biosensors. An ideal sensor surface should be resistant to nonspecific protein adsorption, yet be conducive to analytical responses. Here a new polymeric material, zwitterionic polypyrrole (ZiPPy), is reported to produce optimal surface condition for biosensing electrodes. ZiPPy combines two unique advantages: the zwitterionic function that efficiently hydrates electrode surface, hindering nonspecific binding of hydrophobic proteins; and the pyrrole backbone, which enables rapid (<7 min), controlled deposition of ZiPPy through electropolymerization. ZiPPy-coated electrodes show lower electrochemical impedance and less nonspecific protein adsorption (low fouling), outperforming bare and polypyrrole-coated electrodes. Moreover, affinity ligands for target biomarkers can be immobilized together with ZiPPy in a single-step electropolymerization. ZiPPy-coated electrodes are developed with specificity for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The prepared sensor detects SARS-CoV-2 antibodies in human saliva down to 50 ng mL-1 , without the need for sample purification or secondary labeling.

Multielectrode Spectroscopy Enables Rapid and Sensitive Molecular Profiling of Extracellular Vesicles.

Detecting protein markers in extracellular vesicles (EVs) is becoming a useful tool for basic research and clinical diagnoses. Most EV protein assays, however, require lengthy processes-conjugating affinity ligands onto sensing substrates and affixing EVs with additional labels to maximize signal generation. Here, we present an iPEX (impedance profiling of extracellular vesicles) system, an all-electrical strategy toward fast, multiplexed EV profiling. iPEX adopts one-step electropolymerization to rapidly functionalize sensor electrodes with antibodies; it then detects EV proteins in a label-free manner through impedance spectroscopy. The approach streamlines the entire EV assay, from sensor preparation to signal measurements. We achieved (i) fast immobilization of antibodies (<3 min) per electrode; (ii) high sensitivity (500 EVs/mL) without secondary labeling; and (iii) parallel detection (quadruple) in a single chip. A potential clinical utility was demonstrated by directly analyzing plasma samples from glioblastoma multiforme patients.

Electrochemiluminescence in paired signal electrode (ECLipse) enables modular and scalable biosensing.

Electrochemiluminescence (ECL) has an inherently low background and enables precise chemical reactions through electrical control. Here, we report an advanced ECL system, termed ECLipse (ECL in paired signal electrode). We physically separated ECL generation from target detection: These two processes were carried out in isolated chambers and coupled through an electrode. The strategy allowed us to minimize cross-chemical reactions, design electrodes for high ECL signals, and integrate multiple sensors in a chip. As a proof of concept, we implemented an eight-plex ECLipse and applied it to detect host factors in human plasma. ECLipse achieved higher signal-to-noise ratio than conventional ECL assays and was >7000-fold more sensitive than enzyme-linked immunosorbent assay. In a pilot clinical study, we could detect septic conditions by measuring host factors [i.e., interleukin-3 (IL-3), IL-6, and procalcitonin (PCT)]. ECLipse assay further revealed distinct IL-3 and IL-6 patterns in patients with severe acute respiratory syndrome coronavirus 2 infection.

Diode Laser-Can It Replace the Electrical Current Used in Endoscopic Submucosal Dissection?

BACKGROUND/AIMS: A new medical fiber-guided diode laser system (FDLS) is expected to offer high-precision cutting with simultaneous hemostasis. Thus, this study aimed to evaluate the feasibility of using the 1,940-nm FDLS to perform endoscopic submucosal dissection (ESD) in the gastrointestinal tract of an animal model. METHODS: In this prospective animal pilot study, gastric and colorectal ESD using the FDLS was performed in ex vivo and in vivo porcine models. The completeness of en bloc resection, the procedure time, intraprocedural bleeding, histological injuries to the muscularis propria (MP) layer, and perforation were assessed. RESULTS: The en bloc resection and perforation rates in the ex vivo study were 100% (10/10) and 10% (1/10), respectively; those in the in vivo study were 100% (4/4) and 0% for gastric ESD and 100% (4/4) and 25% (1/4) for rectal ESD, respectively. Deep MP layer injuries tended to occur more frequently in the rectal than in the gastric ESD cases, and no intraprocedural bleeding occurred in either group. CONCLUSION: The 1,940-nm FDLS was capable of yielding high en bloc resection rates without intraprocedural bleeding during gastric and colorectal ESD in animal models.

[A case of jeujunogastric intussusception presented with hematemesis after distal gastrectomy].

Adult intussusception represents 5% of all cases of intussusception and accounts for only 1-5% intestinal obstructions. Intussusception is a rare complication after gastric surgery with an incidence estimated at 0.1%. Early diagnosis of the acute onset intussusception is critical because mortality rates increase abruptly with delay in surgical treatment. We present here a case of jejunogastric intussusception diagnosed by gastroscopy in a patient with a history of distal gastrectomy due to early gastric cancer who had experienced hematemesis.

[Comparison of the cut direction between gross finding, streoscopic finding, and pathologic mapping of endoscopic submucosal dissection Specimen].

BACKGROUND/AIMS: The correct pathologic review is very important after endoscopic submucosal dissection. The cut direction of specimen should be the right angle of the closest area between the lesion and the lateral margin for the correct pathologic review. The aim of this study was to evaluate the concordance of the gross finding and stereoscopic finding compared to the pathologic mapping in the setting of the cut direction. METHODS: Between December 2008 and May 2009, the objects were 48 specimens in 46 patients who were diagnosed with early gastric cancer and high grade adenoma after endoscopic submucosal dissection. The specimens were stained with hematoxylin and observed by the stereoscopy and analyzed by the image analysis system. The cut direction was divided by an angle of 45 degree based on the oral side of the specimen, and the cut directions of the gross finding, the stereoscopic finding, and the pathologic finding were compared. RESULTS: The concordance of the gross finding in the setting of the cut direction was 68% (33/48), and the kappa value was 0.626, and the concordance of the stereoscopic finding in the setting of the cut direction was 87% (33/48), and the kappa value was 0.874. The accuracy of the gross finding was significantly lower than that of the stereoscopic finding in the setting of the cut direction (p<0.05). CONCLUSIONS: The endoscopist needs the careful observation and close attention in the setting of the cut direction of the specimen by gross finding, and stereoscopic analysis may be a useful tool for decision of the cut direction.

Current Status of Peroral Endoscopic Myotomy.

Peroral endoscopic myotomy (POEM) has been established as an optional treatment for achalasia. POEM is an endoluminal procedure that involves dissection of esophageal muscle fibers followed by submucosal tunneling. Inoue first attempted to use POEM for the treatment of achalasia in humans. Expanded indications of POEM include classic indications such as type I, type II, type III achalasia, failed prior treatments, including Botulinum toxin injection, endoscopic balloon dilation, laparoscopic Heller myotomy, and hypertensive motor disorders such as diffuse esophageal spasm, jackhammer esophagus. Contraindications include prior radiation therapy to the esophagus and prior extensive esophageal mucosal resection/ablation involving the POEM field. Most of the complications are minor and self-limited and can be managed conservatively. As POEM emerged as the main treatment for achalasia, various adaptations to tunnel endoscopic surgery have been attempted. Tunnel endoscopic surgery includes POEM, peroral endoscopic tumor resection, gastric peroral endoscopic pyloromyotomy. POEM has been widely accepted as a treatment for all types of achalasia, even for specific cases such as achalasia with failed prior treatments, and hypertensive motor disorders.

Current and Future Use of Esophageal Capsule Endoscopy.

Capsule endoscopy can be a diagnostic option for patients with esophageal diseases who cannot tolerate esophagogastroduodenoscopy.Functional modifications of the capsule allow for thorough examination of the esophagus. Esophageal capsule endoscopy has so farfailed to show sufficient performance to justify the replacement of traditional endoscopy for the diagnosis of esophageal diseasesbecause the esophagus has a short transit time and common pathologies appear near the esophagogastric junction. However,technological improvements are being introduced to overcome the limitations of capsule endoscopy, which is expected to become agood alternative to conventional endoscopy.

Dissolution Behavior and Biodurability of Ingested Engineered Nanomaterials in the Gastrointestinal Environment.

Engineered nanomaterials (ENM) are extensively used as food additives in numerous food products, and at present, little is known about the fate of ingested ENM (iENM) in the gastrointestinal (GI) environment. Here, we investigated the dissolution behavior, biodurability, and persistence of four major iENM (TiO2, SiO2, ZnO, and two Fe2O3) in individual simulated GI fluids (saliva, gastric, and intestinal) and a physiologically relevant digestion cascade (saliva → gastric → intestinal) in the fasted state over physiologically relevant time frames. TiO2 was found to be the most biodurable and persistent iENM in simulated GI fluids with a maximum of only 0.42% (4 µM Ti4+ ion release) dissolution in cascade digestion, followed by iron oxides, of which the rod-like morphology was more biodurable and persistent (0.7% maximum dissolution, 8.7 µM Fe3+) than the acicular one (2.27% maximum dissolution, 16.7 µM Fe3+) in the cascade digestion, respectively. SiO2 and ZnO were less biodurable than Fe2O3, with 65.5% (416 µM Si4+) and 100% (1718.1 µM Zn2+) dissolution in the gastric phase, respectively. In the intestinal phase, however, Si4+ ions reprecipitated, possibly due to sudden pH changes, while ZnO remained completely dissolved. These observations were also confirmed using high-resolution particle size and concentration, and electron microscopy, time-dependent analysis. In terms of decreasing biodurability and persistence in the simulated GI environment, the tested nanomaterials can be ranked as follows: TiO2 ≫ rod-like Fe2O3 > acicular Fe2O3 ≫ SiO2 > ZnO, which is in agreement with limited animal biokinetics data. Chronic uptake of these iENM as particles or ions by the GI tract, especially in the presence of a food matrix and authentic digestive media, and associated implications for human health warrants further investigation.

Hybrid Natural Orifice Transluminal Endoscopic Surgery with Sentinel Lymph Node Navigation for Deep Early Gastric Cancer in the Fundic Region.

For patients refusing surgical treatment for deep early gastric cancer, hybrid natural orifice transluminal endoscopic surgery with sentinel lymph node navigation is a potential treatment option, particularly when the anatomic location of the cancer has low probability of lymph node metastasis. We report a case of deep early gastric cancer of the fundus beyond the endoscopic submucosal dissection indication that was treated by hybrid natural orifice transluminal endoscopic surgery with sentinel lymph node navigation. In a conventional approach, a total gastrectomy would have been needed; however, the patient refused surgical intervention. In this case, since the patient showed no positivity of the sentinel lymph node on intraoperative navigation, laparoscopic basin lymph node dissection was not performed. Hybrid natural orifice transluminal endoscopic surgery might be considered for specific regions such as the safety zone where lymph node metastases are less likely to occur.

Reappraisal of Pneumoperitoneum After Percutaneous Endoscopic Gastrostomy.

BACKGROUND/AIMS: Pneumoperitoneum is recognized as a benign and self-limiting finding after the insertion of a percutaneous endoscopic gastrostomy (PEG) tube, while complicated pneumoperitoneum is rarely reported. The aim of this study was to reappraise pneumoperitoneum following PEG. METHODS: We retrospectively reviewed 193 patients who underwent PEG from May 2008 to May 2014. All patients had a follow-up upright chest or simple abdominal radiograph after PEG. Pneumoperitoneum was quantified by measuring the height of the air column under the diaphragm and graded as small (<2 cm), moderate (2-4 cm), or large (>4 cm). Clinically significant signs were defined as fever, abdominal tenderness or leukocytosis occurring after PEG insertion. RESULTS: Of the 193 study patients, 9 (4.6%) had a pneumoperitoneum visualized by radiographic imaging, graded as small in 5 patients, moderate in 2 patients and large in 2 patients. Clinically significant signs were observed in 5 (55.5%) patients with fever reported in 4 patients, abdominal tenderness in 4 patients and leukocytosis in 4 patients. The time to resolution of free air was 2-18 days. Two patients (22.2%) with moderate or large pneumoperitoneum after PEG died from either pneumonia or septic shock. CONCLUSIONS: The clinical course of pneumoperitoneum after PEG is not always benign and self-limiting. These findings suggest that clinicians should not neglect a moderate or large pneumoperitoneum, particularly in patients who have an altered mental status or received antibiotics, since peritoneal irritation cannot be observed under these circumstances.

[A case of the ruptured splenic artery aneurysm treated with transcatheter embolization].

Splenic artery aneurysms are the most common visceral artery aneurysms, which are usually found incidentally. The most common complication of splenic artery aneurysms is spontaneous rupture into the peritoneal cavity, which leads to acute peritonitis and shock. Less commonly, it may rupture directly into the stomach, small bowel or pancreatic duct and may present with acute gastrointestinal hemorrhage. We report a rare case of the ruptured splenic artery aneurysm, presenting as acute massive hematochezia which was treated with transcatheter embolization.

A case report of primary duodenal tuberculosis mimicking a malignant tumor.

Tuberculosis remains a serious infectious disease with primary features of pulmonary manifestation in Korea. However, duodenal tuberculosis is rare in gastrointestinal cases of extrapulmonary tuberculosis. Here, we report a case of primary duodenal tuberculosis mistaken as a malignant tumor and diagnosed with QuantiFERON-TB GOLD (Cellestis Ltd.) in an immunocompetent male patient.