ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction

This American Society for Gastrointestinal Endoscopy guideline provides evidence-based recommendations for the endoscopic management of gastric outlet obstruction (GOO). We applied the Grading of Recommendations, Assessment, Development and Evaluation methodology to address key clinical questions. These include the comparison of (1) surgical gastrojejunostomy to the placement of self-expandable metallic stents (SEMS) for malignant GOO, (2) covered versus uncovered SEMS for malignant GOO, and (3) endoscopic and surgical interventions for the management of benign GOO. Recommendations provided in this document were founded on the certainty of the evidence, balance of benefits and harms, considerations of patient and caregiver preferences, resource utilization, and cost-effectiveness.

A large multicenter cohort on the use of full-thickness resection device for difficult colonic lesions.

BACKGROUND: Introduction of the full-thickness resection device (FTRD) has allowed endoscopic resection of difficult lesions such as those with deep wall origin/infiltration or those located in difficult anatomic locations. The aim of this study is to assess the outcomes of the FTRD among its early users in the USA. METHODS: Patients who underwent endoscopic full-thickness resection (EFTR) for lower gastrointestinal tract lesions using the FTRD at 26 US tertiary care centers between 10/2017 and 12/2018 were included. Primary outcome was R0 resection rate. Secondary outcomes included rate of technical success (en bloc resection), achievement of histologic full-thickness resection (FTR), and adverse events (AE). RESULTS: A total of 95 patients (mean age 65.5 ± 12.6 year, 38.9% F) were included. The most common indication, for use of FTRD, was resection of difficult adenomas (non-lifting, recurrent, residual, or involving appendiceal orifice/diverticular opening) (66.3%), followed by adenocarcinomas (22.1%), and subepithelial tumors (SET) (11.6%). Lesions were located in the proximal colon (61.1%), distal colon (18.9%), or rectum (20%). Mean lesion diameter was 15.5 ± 6.4 mm and 61.1% had a prior resection attempt. The mean total procedure time was 59.7 ± 31.8 min. R0 resection was achieved in 82.7% while technical success was achieved in 84.2%. Histologically FTR was demonstrated in 88.1% of patients. There were five clinical AE (5.3%) with 2 (2.1%) requiring surgical intervention. CONCLUSIONS: Results from this first US multicenter study suggest that EFTR with the FTRD is a technically feasible, safe, and effective technique for resecting difficult colonic lesions.

Estradiol modulation of astrocytes and the establishment of sex differences in the brain.

The role of steroid hormones as a conduit for reciprocal glial-neuronal communication is an emerging but relatively unexplored concept. Research in our laboratory has discovered that the relationship between astrocytic and neuronal morphology during development is distinct for different brain regions and provides a fundamental basis for region-specific sexual differentiation. The functional significance of estradiol-induced differentiation of astrocytes and the cross-talk of these cells with neurons includes permanent changes in synaptic patterning and control of adult reproductive behaviors. The cellular mechanisms as currently understood for each region are discussed and unanswered questions as well as other areas for future research are reviewed.

Sexual differentiation of astrocyte morphology in the developing rat preoptic area.

The preoptic area is an important brain region controlling sex-typic behaviour and physiology, and astrocytes of this region are responsive to steroids perinatally. Utilizing glial fibrillary acidic protein immunocytochemistry, the morphology of astrocytes in the preoptic area of male and female rat pups was examined on the day of birth and on postnatal day 3. As early as the day of birth, astrocytes of the male preoptic area exhibit both significantly greater primary process length and number of primary processes, and these differences remain at postnatal day 3. Application of exogenous steroid to females suggested that gonadal steroids, in particular oestradiol, mediate the sex difference. Pups received 100 micro g of steroid on the day of birth and again on postnatal day 1, and astrocyte morphology was assessed on postnatal day 3. Both oestradiol and testosterone induced significant changes in process length and number compared to vehicle-treated controls. Astrocytes of oestradiol-treated females did not differ on PN3 from those of PN3-untreated males. Exposure to the nonaromatizable steroid, dihydrotestosterone, had no effect on any attribute of astrocyte morphology. This suggests the effects induced by testosterone are mediated by oestradiol following local aromatization of the steroid, and not through direct activation of the androgen receptor. Astrocytes are important in synapse formation and efficacy, and we hypothesize a role for astrocyte complexity and differentiation in the establishment of synaptic patterning.

Cytoarchitecture of vocal control nuclei in nestling budgerigars: relationships to call development.

Changes in the cytoarchitecture of vocal control nuclei were investigated in nestling budgerigars (Melopsittacus undulatus) from hatching to fledging (five to six weeks) in relation to changes in vocalizations produced by nestlings during this period. The nuclei investigated were the hypoglossal nucleus, dorsomedial nucleus of the intercollicular midbrain, central nucleus of the archistriatum, central nucleus of the lateral neostriatum, oval nucleus of the hyperstriatum ventrale, medial division of the oval nucleus of the anterior neostriatum, and magnocellular nucleus of the lobus parolfactorius. These nuclei have been shown to form functional circuits in adults related to vocal learning. Consistent with previously reported results, we found that call development could be described in terms of five different phases based on changes in the duration and segmentation of single and multiple segment food begging calls and the appearance of the first socially learned contact calls around the time of fledging. We also found that call segment duration exhibited an inverted U-shaped developmental function during the nestling period, as has been found for total call duration. Cytoarchitectonic studies revealed striking changes in the cellular architecture of vocal control nuclei during the first four weeks posthatching. At hatching the hypoglossal nucleus exhibits adult-like cytoarchitecture, and the central nucleus of the archistriatum and the central nucleus of the lateral neostriatum are distinguishable from surrounding fields. By one week posthatch, the central nucleus of the archistriatum exhibits an adult-like appearance, while other telencephalic vocal control nuclei do not exhibit adult-like cytoarchitecture until three to four weeks posthatching. By two weeks posthatching, the dorsomedial nucleus of the intercollicular midbrain also exhibits adult-like cytoarchitecture. We observed substantial decreases in the thickness of ventricular proliferation zones during this period, with decreases in ventricular zones occurring at about the same point that nuclei at corresponding levels come to exhibit adult-like cytoarchitectonic features. Of interest is the fact that cytoarchitectural development occurs asynchronously in different brain regions, with the appearance of adult-like characteristics in the hindbrain and midbrain occurring before the appearance of adult-like cytoarchitectonic characteristics in telencephalic nuclei. These results are consistent with recent lesion studies indicating that neither auditory feedback nor telencephalic vocal control nuclei are necessary for the production of food begging and other nestling calls until three to four weeks posthatching.

Vocal control pathways through the anterior forebrain of a parrot (Melopsittacus undulatus).

A feature of the telencephalic vocal control system in the budgerigar (Melopsittacus undulatus) that has been hypothesized to represent a profound difference in organization from the oscine vocal system is its reported lack of an inherent circuit through the anterior forebrain. The present study reports anatomical connections that indicate the existence of an anterior forebrain circuit comparable in important ways to the "recursive" pathway of oscine songbirds. Results from anterograde and retrograde tracing experiments with biocytin and fluorescently labeled dextran amines indicate that the central nucleus of the anterior archistriatum (AAc) is the source of ascending projections upon the oval nuclei of the anterior neostriatum and ventral hyperstriatum (NAo and HVo, respectively). Efferent projections from the latter nuclei terminate in the lateral neostriatum afferent to AAc, thereby forming a short recurrent pathway through the pallium. Previously reported projections from HVo and NAo upon the magnocellular nucleus of the lobus parolfactorius (LPOm), and after LPOm onto the magnocellular nucleus of the dorsal thalamus (DMm; G.F. Striedter [1994] J. Comp. Neurol. 343:35-56), are confirmed. A specific projection from DMm onto NAom is also demonstrated; therefore, a recurrent pathway through the basal forebrain also exists in the budgerigar vocal system that is similar to the anterior forebrain circuit of oscine songbirds. Parallels between these circuits and mammalian basal ganglia-thalamo-cortical circuits are discussed. It is hypothesized that vocal control nuclei of the avian anterior neostriatum may perform a function similar to the primate supplemental motor area.