Submucosal tunneling endoscopic full-thickness resection for management of a rare case of esophageal GI stromal tumor.

Video 1The mass was identified at the upper- to mid-esophagus, 25 cm from the central incisors. No varices were seen on further examination of the esophagus. A 4-mm injector force needle was used to create a large submucosal injection using BlueBoost lifting agent proximal to the mass. A longitudinal mucosal incision was then made using the hybrid T-type electrocautery knife, 20 cm from the central incisors.The cutting current was the preset Endocut Q mode, and the coagulation setting was spray coag mode, effect 2 and 40 W.Next, tunnel creation by submucosal dissection was performed with a focus on keeping the submucosal space as clean as possible. Carbon dioxide was used for insufflation to prevent pneumoperitoneum.A smooth-surfaced oval mass was identified originating from the muscularis propria layer. Dissection was extended 2 cm distally beyond the mass. Next, resection of the mass was performed. First, the mucosal surface of the mass was dissected. Dissection began at the distal portion, proceeded to the left and right lateral borders, and then continued toward the proximal portion. The mass was dissected away from the muscularis propria.We focused on freeing the mass, ensuring this esophageal mass was intact throughout dissection. The attached bands of muscularis propria at the distal portion were carefully resected completely.Water irrigation was used at this time to ensure better visualization for resection. The remaining attached bands of muscularis propria were resected, ensuring complete en bloc resection. Afterward, the mass was suctioned into the cap and carefully retrieved as shown, and then sent to pathology for processing.The entire defect bed was inspected post-resection, and no perforation or bleeding was identified.The mucosal defect was completely closed with through-the-scope hemostatic clips in a longitudinal fashion beginning with approximation of the defect at the distal portion.

Pyloric Gastric Adenoma: Endoscopic Detection, Removal, and Echoendosonographic Characterization.

Pyloric gland adenomas (PGAs) are rare neoplasms found not only in the gastrointestinal tract but also in other extragastrointestinal organs. They have potential for malignant conversion, and early detection and removal is imperative to prevent invasive disease. PGAs prove difficult in management and surveillance given their rarity. However, increasing familiarity with histological appearance and use of advanced tools such as echoendosonography can bring greater understanding of their clinical history. We describe a unique case of a PGA detected within a hiatal hernia sac characterized with echoendosonography and highlight the need to develop surveillance protocols for these types of lesions.

Enhanced suction for removal of esophageal food impaction.

Video 1Enhanced suction for removal of esophageal food impaction.

Natural orifice transendoscopic surgery as a rescue for a dislodged lumen-apposing metal stent in the peritoneum after successful EUS-directed transgastric ERCP.

Video 1Natural orifice transendoscopic surgery as a rescue for a dislodged lumen-apposing metal stent after EUS-directed transgastric ERCP.

Continuing Medical Education Questions: May 2023.

Article Title: Reduced Adenoma Miss Rate with 9-Minute vs 6-Minute Withdrawal Times for Screening Colonoscopy: A Multicenter Randomized Tandem Trial.

Use of a novel articulation arm device for endoscopic submucosal dissection of a rectal laterally spreading tumor.

Video 1.

Benchmarking definitions of false-positive alerts during computer-aided polyp detection in colonoscopy.

BACKGROUND: The occurrence of false-positive alerts is an important outcome measure in computer-aided colon polyp detection (CADe) studies. However, there is no consensus definition of a false positive in clinical trials evaluating CADe in colonoscopy. We aimed to study the diagnostic performance of CADe based on different threshold definitions for false-positive alerts. METHODS: A previously validated CADe system was applied to screening/surveillance colonoscopy videos. Different thresholds for false-positive alerts were defined based on the time an alert box was continuously traced by the system. Primary outcomes were false-positive results and specificity using different threshold definitions of false positive. RESULTS: 62 colonoscopies were analyzed. CADe specificity and accuracy were 93.2 % and 97.8 %, respectively, for a threshold definition of ≥ 0.5 seconds, 98.6 % and 99.5 % for a threshold definition of ≥ 1 second, and 99.8 % and 99.9 % for a threshold definition of ≥ 2 seconds. CONCLUSION: Our analysis demonstrated how different threshold definitions of false positive can impact the reported diagnostic performance of CADe for colon polyp detection.

Emerging use of artificial intelligence in inflammatory bowel disease.

Inflammatory bowel disease (IBD) is a complex, immune-mediated gastrointestinal disorder with ill-defined etiology, multifaceted diagnostic criteria, and unpredictable treatment response. Innovations in IBD diagnostics, including developments in genomic sequencing and molecular analytics, have generated tremendous interest in leveraging these large data platforms into clinically meaningful tools. Artificial intelligence, through machine learning facilitates the interpretation of large arrays of data, and may provide insight to improving IBD outcomes. While potential applications of machine learning models are vast, further research is needed to generate standardized models that can be adapted to target IBD populations.

A Case of Granulocytic Sarcoma or Extramedullary Acute Myelomonocytic Leukemia of the Gallbladder.

BACKGROUND Granulocytic sarcoma, or 'chloroma,' due to extramedullary acute myeloid leukemia (AML) or due to acute myelomonocytic leukemia (AML M5), is rare and is associated with a poor prognosis. This report is of a case of granulocytic sarcoma of the gallbladder and describes the approach to diagnosis and treatment. CASE REPORT A 74-year-old Hispanic woman from Ecuador presented to the emergency department with a five-day history of fever, jaundice, and right upper quadrant abdominal pain. The right upper quadrant ultrasound showed a thickened gallbladder wall with cholelithiasis, a positive sonographic Murphy sign, and marked dilatation of the common bile duct, which was up to 17 mm in diameter. Endoscopic retrograde cholangiopancreatography (ERCP) showed purulence and a stone in the common bile duct, which was removed. She underwent laparoscopic cholecystectomy which identified gangrenous cholecystitis. Despite cholecystectomy and treatment with broad-spectrum antibiotics, she remained febrile with a leukocytosis of up to 80,000 cells/µL. Histopathology of the gallbladder showed infiltrating myeloblasts within the mucosa, submucosa, and muscularis consistent with a granulocytic sarcoma associated with gangrenous cholecystitis due to cholelithiasis. Immunohistochemistry, using a panel of antibodies to CD33, CD68, HLA-DR, and lysozyme, supported the diagnosis of granulocytic sarcoma or extramedullary acute myelomonocytic leukemia (AML M5). CONCLUSIONS A rare case of an extramedullary hematologic malignancy, granulocytic sarcoma of the gallbladder is presented, which highlights the importance of timely diagnosis and treatment, due to the high mortality rate associated with granulocytic sarcoma, or extramedullary AML.