BACKGROUND In recent years, endoscopic resection (ER) has been employed for the excision of submucosal tumors (SMTs). Nonetheless, ER in the duodenum is linked to elevated risks of both immediate and delayed hemorrhagic complications and perforations. Satisfactory suturing is crucial for reducing the occurrence of complications. AIM To establish a clinical score model for supporting suture decision-making of duodenal SMTs. METHODS This study included 137 individuals diagnosed with duodenal SMTs who underwent ER. Participants were evenly divided into two groups: A training cohort (TC) comprising 95 cases and an internal validation cohort (VC) with 42 cases. Subsequently, a scoring system was formulated utilizing multivariate logistic regression analysis within the TC, which was then subjected to evaluation in the VC. RESULTS The clinical scoring system incorporated two key factors: Extraluminal growth, which was assigned 2 points, and endoscopic full-thickness resection, which was given 3 points. This model demonstrated strong predictive accuracy, as evidenced by the area under the receiver operating characteristic curve of 0.900 (95% confidence interval: 0.823-0.976). Additionally, the model’s goodness-of-fit was validated by the Hosmer-Lemeshow test (P = 0.404). The probability of purse-string suturing in low (score 0-2) and high (score > 3) categories were 3.0% and 64.3% in the TC, and 6.1% and 88.9% in the VC, respectively. CONCLUSION This scoring system may function as a beneficial instrumentality for medical practitioners, facilitating the decision-making process concerning suture techniques in the context of duodenal SMTs.
The spectrum of endoscopic resection methods, including full thickness techniques, has enabled removal of most smaller gastric submucosal tumours (SMTs). We developed an extended transmural endoscopic dissection technique for lesions with predominately extraluminal growth arising from the muscularis propria. It consists of transmural intraperitoneal access with the endoscope besides the lesion followed by subserosal dissection from the outside. The technique was successful in two patients with smaller (2–3 cm) gastric stromal tumours; lesions were resected completely and short-term follow-up was normal. Further studies are warranted to confirm the safety and feasibility of this this new approach.
With the popularisation of endoscopy and the development of endoscopic ultrasonography (EUS), the detection rate of gastrointestinal (GI) SMT has increased significantly.1 Complete surgical resection is still recognised as the primary and the most important way to treat gastric SMT and to get clear pathological diagnosis.2 Minimally invasive endoscopic therapy received increasing recognition due to its advantages of less invasiveness, fewer complications, quicker recovery and lower costs compared with open surgery or laparoscopic surgery. Gastric SMTs derived from mucosal and submucosal layers could be resected by endoscopic mucosal resection and endoscopic submucosal dissection, while those originated from deep layers of the gastric wall can be resected using endoscopic full-thickness resection (EFTR), which intentionally perforates the gastric wall to achieve complete resection.3 With an increasing emphasis on protecting the intact of mucosa, endoscopic mucosa-sparing lateral dissection was developed to reduce the postoperative complications.4 Inspired by the submucosal tunnelling endoscopic resection (STER)5 technique, in which maintenance of mucosal integrity and the longitudinal submucosal tunnel lead to rapid healing and decreased risk of pleural infection, STER for extraluminal tumours was reported for resection of SMTs with a predominant extraluminal growth pattern or extra-GI tumours.6 However, for most SMTs with a predominately extraluminal …
To explore whether injury and repair occur in the trachea and the lung after intra-tracheal administration of different drugs.Wistar rats were randomly divided into 5 groups, a normal group, a blank control (BC) group, a normal saline (NS) group, a lidocaine (LD) group and an amikacin (AK) group. For the latter 3 groups, normal saline, lidocaine and amikacin were injected into trachea by needle puncture. Scanning electron microscope was used to observe the ultra-structural changes of the epithelium, and the percentage of the area of damage (PAD) in tracheal mucosa was calculated. Moreover, pathological changes of the mucous membrane of bronchioles and alveolar epithelial cells were also examined, and the degree of lung pathology was semi-quantified.Two hours after the injection of the 3 drugs, derangement and edema of the cilia were evident by scanning electron microscopy. The PAD of the NS group, the LD group and the AK group were (94.2 ± 3.2)%, (93.1 ± 3.0)% and (95.5 ± 1.8)%, respectively; all being significantly higher than that of the BC group (1.3 ± 0.3)%. For the NS group and the LD group, the PAD decreased significantly after 24 h, which were (73.7 ± 7.8)% and (81.0 ± 4.6)% respectively, and returned to normal at 48 h and 96 h. While for the AK group, the damage began to improve at 72 h [PAD (62.1 ± 5.2)%], and recovered at 96 h. Airway epithelial derangement and cell edema in the alveoli and the bronchioles also occurred 2 h after drug injection, and inflammatory cell infiltration became evident at 24 h. At this time, the score of pathology was 1.80 ± 0.84, 2.60 ± 0.55 and 2.80 ± 0.45 for the NS group, the LD group and the AK group, respectively; all being higher than that of the BC group (0). These pathological changes recovered totally after 72 h for the NS and the LD groups, and 96 h for the AK group.Intra-tracheal administration of normal saline, lidocaine and amikacin in rats led to reversible airway mucosal and lung tissue damages.
Delayed bleeding is a rare but important major adverse event (mAE) after endoscopic submucosal tunneling procedures (ESTP), which is scarcely reported. We aimed to characterize the clinical characteristics of delayed bleeding and provide better management of this mAE.From August 2010 to October 2022, we reviewed 3852 patients with achalasia receiving peroral endoscopic myotomy (POEM) and 1937 patients with upper gastrointestinal tumors receiving submucosal tunneling endoscopic resection (STER). Among these, records of 22 patients (15 POEM, 7 STER) with delayed bleeding were collected. Clinical characteristics, treatment, and outcomes of delayed bleeding were analyzed.The mean age was 43.6 years. Ten patients (45.5%) were intratunnel bleeding, seven (31.8%) were intratunnel bleeding accompanied by mucosal bleeding, and five (22.7%) were mucosal bleeding. The most common accompanied symptoms were hematemesis, fever, and melena. The most common accompanied mAEs were fistula, pulmonary inflammation, and pleural effusion with atelectasis. The mean duration from ESTP to endoscopic intervention was 5.3 ± 4.9 days. Active bleeding was identified in 21 patients (95.5%). The bleeding was successfully controlled by electrocoagulation (19 cases), endoscopic clipping (six cases), and Sengstaken-Blakemore tube insertion (three cases), and no patient required surgical intervention. The mean hemostatic procedure duration was 61.8 ± 45.8 min. The mean post-bleeding hospital stay was 10.0 ± 6.2 days. A brief meta-analysis of previous studies showed the pooled estimate delayed bleeding rate after POEM, STER, and G-POEM was 0.4%.Delayed bleeding is uncommon and could be effectively managed by timely emergency endoscopic procedures without requiring subsequent surgical interventions.
Intravenous leiomyomatosis is characterized by a proliferation of benign smooth muscular tissue growing into uterine with malignant appearance. On extremely rare occasions, the tumor may grow out of the pelvis and extend into the inferior vena cava and the right atrium. We report a case of intravenous leiomyomatosis extending into the right atrium. A 41-year-old woman complained of 20 days of intermittent abdominal pain and lower limbs swell. Medical history of the patient revealed a previous hysterectomy operation 3 years ago due to uterine leiomyoma. Echocardiography showed a homogenous mass extending from the inferior vena cava to the right atrium, without evidence of adherence to the right atrial wall, the left ventricular ejection fraction was only 60%. Computer tomography showed that a large mass arising from the left internal iliac vein and extending into the right chambers. Pelvic vascular ultrasound revealed the thrombotic material in the inferior vena cava and the left common iliac vein, and confirmed the presence of a complex mass in the left annex region. Based on the findings, the initial diagnosis was intracardiac and intravenous tumor. An operation was performed through a sternotomy and laparotomy to remove the whole tumor from the left common iliac vein to the right atrium, ligate left internal iliac vein mean-wile. No hormonal therapy was administrated after the operation. Immunohistochemical studies revealed that the tumor cells were fusiform shape, there was no karyokinesis and necrosis, and the tumor cells were positive for smooth muscle antigen and desmin, as well as estrogen receptor and progesterone receptor. Six months postoperation follow-up revealed no signs of recurrence. The differential diagnosis of the disease compared with primary cardiovascular sarcomas and thrombus was difficult. The final diagnosis relied on immunohistochemical analysis, however, the short-term result of operation was acceptable.
Objective
To evaluate the feasibility, safety and efficacy of repeated peroral endoscopic myotomy (Re-POEM) as a make-up therapy after POEM failure.
Methods
Thirty-three patients with persistent/recurrent symptoms after first POEM (Eckardt symptom score≥4) were selected from a database of a total of 2 516 consecutive patients with achalasia. The main outcome measures was Eckardt score during follow-up; the secondary outcome measures were procedure-related adverse events, changes in manometric lower esophageal sphincter (LES) pressure, and reflux symptoms before and after Re-POEM.
Results
All patients successfully underwent Re-POEM in mean 18.6 months (ranging 3-55 months) after their first POEM procedures. The mean symptom score before Re-POEM was 5.5 (ranging 4-8). Mean operation time was 45.1 minutes (ranging 28-64 minutes). Submucosal tunnel infection occurred in 1 patient who recovered with conservative treatment. During a mean follow-up period of 36.6 months (ranging 12-58 months), symptom relief was achieved in all patients. Eckardt score reduced to 1.3 (ranging 0-3), significantly different from that before (P<0.001). Mean LES pressure also declined from 26.0 mmHg (1 mmHg=0.133 kPa) to 9.6 mmHg after Re-POEM (P<0.001). The incidence of gastroesophageal reflux of Re-POEM was 33.3% (11/33).
Conclusions
Re-POEM appears safe and effective as a make-up option after POEM failure.
Key words:
Esophageal achalasia; Peroral endoscopic myotomy; Repeated peroral endoscopic myotomy
Objective
To evaluate the safety, feasibility, perioperative and long-term efficacy of peroral endoscopic myotomy (POEM) for achalasia (AC) in geriatric patients.
Methods
Data of 41 patients aged over 65 diagnosed with achalasia and treated with POEM in Zhongshan Hospital from August 2010 to December 2014 were retrospectively studied. Perioperative complications, preoperative and postoperative Eckardt score and pressure of the lower esophageal sphincter, esophageal reflux and clinical failure were analyzed.
Results
All 41 patients underwent POEM successfully, with median operation time of 42 min. Median hospitalization was 3 days. Major perioperative adverse events occurred in 4 cases (9.75%), whose hospitalization was longer than 5 days for perioperative adverse events. During median follow-up period of 40 months (interquartile range 24-57 months), median Eckardt score decreased from 8 to 1(P<0.001)and pressure of the lower esophageal sphincter decreased from 23.85 mmHg(1 mmHg=0.133 kPa) to 9.05 mmHg (P=0.005). Clinical reflux occurred in 12 cases (29.27%) and the 5-year success rate of POEM was 87.80% (36/41).
Conclusion
POEM is a safe and reliable treatment for geriatric AC patients with confirmed short-term and long-term effectiveness.
Key words:
Esophageal achalasia; Geriatrics; Peroral endoscopic myotomy
Most pro-neuropeptides are processed by the prohormone convertases, PC1 and PC2. We previously reported that changes in thyroid status altered anterior pituitary PC1 mRNA and this regulation was due to triiodothyronine (T(3))-dependent interaction of thyroid hormone receptor (TR) with negative thyroid hormone response elements (nTREs) contained in a large region of the human PC1 promoter. In this study, we demonstrated that hypothyroidism stimulated, while hyperthyroidism suppressed, PC1 mRNA levels in rat hypothalamus and cerebral cortex, but not in hippocampus. In situ hybridization was used to confirm real-time PCR changes and localize the regulation within the hypothalamus and cortex. Using a human PC1 (hPC1) promoter construct (with and without deletions in two regions that each contain a negative TRE) transiently transfected into GH3 cells, we found that T(3) negatively regulated hPC1 promoter activity, and this regulation required both of these two regions. Electrophoretic mobility shift assays (EMSAs) using purified thyroid hormone receptor alpha1 (TRalpha1) and retinoid X receptor beta (RXRbeta) proteins demonstrated that RXR and TRalpha both bound the PC1 promoter. Addition of TRalpha1/RXRbeta to the wild-type PC1 probe demonstrated binding as both homodimers and a heterodimer. EMSAs with oligonucleotides containing deletion mutations of the putative nTREs demonstrated that the proximal nTRE binds more strongly to TR and RXR than the distal nTRE, but that both regions exhibit specific binding. We conclude that there are multiple novel TRE-like sequences in the hPC1 promoter and that these regions act in a unique manner to facilitate the negative effect of thyroid hormone on PC1.
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