Pseudo-submucosal tumor in the colon: seeing is believing.

A 65-year-old woman was admitted to our hospital with complaints of lower abdominal pain. Her physical examination was unremarkable. The results of routine laboratory testing were within the normal limits. In addition, abdominal CT was normal. Colonoscopy showed a cecum submucosal tumor with a pale yellow surface. Endoscopic ultrasound revealed homogeneous hypoechoic lesions originated from submucosal layer. ESD was subsequently performed to remove the submucosal lesion. During the ESD procedure, fecal outflowed from appendix opening . Yellow fecal-like material was visible after submucosal incision. The trap electrocut surface uplift showed more fecal attachment on the lamina propria surface, and myolayer integrity after clean the fecal (Fig1c), The final pathology of the surface bulge suggested hyperplasia (Fig1d). Patients were discharged with relieved lower abdominal pain. The final diagnosis was submucosal fecalith mimicking a submucosal tumor, eventually leads to chronic appendicitis. Common causes of cecal submucosal tumor include neuroendocrine tumors, lipomas, etc. There was few report about fecalith mimicking a submucosal tumor. ERTA is currently an effective endoscopic method for treating appendicitis combined with fecalith blockage. To our knowledge, this is the first report on a case of cecum submucosal fecalith mimicking a submucosal tumor and was successfully removed using endoscopy.

Endoloop pre-ligation assisted resection of a giant Brunner's gland adenoma of the duodenal bulb.

Brunner's gland adenoma (BGA), also known as Brunneroma or polypoid hamartoma, is a rare benign duodenal tumor that proliferates from Brunner's glands of the duodenum. They are usually asymptomatic and discovered by chance during endoscopy. Some giant lesions can sometimes present with chronic abdominal pain, nausea, vomiting, and anemia, including gastrointestinal bleeding and obstructive symptoms, and need to be resected by surgery or endoscopy. Here we report a giant BGA that was easily and safely removed by Endoloop pre-ligation assisted resection.

Pseudo-submucosal tumor in the colon: seeing is believing

A 65-year-old woman was admitted to our hospital with complaints of lower abdominal pain. Her physical examination was unremarkable. The results of routine laboratory testing were within the normal limits. In addition, abdominal CT was normal. Colonoscopy showed a cecum submucosal tumor with a pale yellow surface. Endoscopic ultrasound revealed homogeneous hypoechoic lesions originated from submucosal layer. ESD was subsequently performed to remove the submucosal lesion. During the ESD procedure, fecal outflowed from appendix opening . Yellow fecal-like material was visible after submucosal incision. The trap electrocut surface uplift showed more fecal attachment on the lamina propria surface, and myolayer integrity after clean the fecal (Fig1c), The final pathology of the surface bulge suggested hyperplasia (Fig1d). Patients were discharged with relieved lower abdominal pain. The final diagnosis was submucosal fecalith mimicking a submucosal tumor, eventually leads to chronic appendicitis. Common causes of cecal submucosal tumor include neuroendocrine tumors, lipomas, etc. There was few report about fecalith mimicking a submucosal tumor. ERTA is currently an effective endoscopic method for treating appendicitis combined with fecalith blockage. To our knowledge, this is the first report on a case of cecum submucosal fecalith mimicking a submucosal tumor and was successfully removed using endoscopy. (AU)

Influence of stone load on the outcome of same-session flexible ureteroscopy for bilateral upper urinary tract stones: a multicenter retrospective study.

Purpose: This study aimed to evaluate the efficacy and safety of same-session flexible ureteroscopy (fURS) for the treatment of bilateral upper urinary tract stones and to examine the influence of stone load on the outcome of same-session fURS, stratifying by total diameter of stones (TDS) ≤30 mm vs. >30 mm. Patients and methods: We retrospectively reviewed all cases of same-session fURS performed for bilateral upper urinary tract stones at four institutions between January 2017 and September 2020. All patients were divided into two groups based on TDS, ≤30 mm and >30 mm. Data on patient demographics, stone characteristics, surgical results, and complications were collected and analyzed for differences between the two groups. Stone-free rate (SFR) was defined as patients endoscopically stone-free or with radiological fragments <2 mm of each renal unit. Results: A total of 121 patients with bilateral upper urinary tract stones underwent same-session fURS, consisting of 73 patients in the TDS ≤ 30 mm group and 48 patients in the TDS > 30 mm group. The mean bilateral stone size was 28.2 ± 12.2 mm (range: 9.1-38.4 mm), with a mean operating time of 97.1 ± 39.6 min (range: 19-220 min). The SFR was 54.5% after the first fURS, and SFR increased to 97.5% after re-fURS for residual stones. The operation time for the TDS > 30 mm group was longer than that of the TDS ≤ 30 mm group (85.1 ± 36.5 vs. 115.4 ± 37.4 min, p < 0.001). The SFR after the first fURS was significantly lower in the TDS > 30 mm group than in the TDS ≤ 30 mm group (25.0% vs. 73.9%, p < 0.001). Although there was no statistically significant difference in overall SFR between the two groups (93.7% vs. 100%, p = 0.060), the rate of re-fURS for residual stones was higher in the TDS > 30 mm group than in the TDS ≤ 30 mm group (75% vs. 26%, p < 0.001). There were no significant differences in length of hospital stay (LOS) (2.2 ± 0.7 vs. 2.3 ± 1.0, p = 0.329) or complication rate (10.9% vs. 14.6%, p = 0.582) between the two groups. Conclusion: The results suggested that same-session fURS can be effectively performed with a low complication rate. A higher SFR after the first fURS can be achieved in the case of bilateral upper urinary tract stones with TDS ≤ 30 mm, and priority should be given to same-session fURS.

Voltage-Mode Ferroelectric Synapse for Neuromorphic Computing.

Ferroelectric materials with a modulable polarization extent hold promise for exploring voltage-driven neuromorphic hardware, in which direct current flow can be minimized. Utilizing a single active layer of an insulating ferroelectric polymer, we developed a voltage-mode ferroelectric synapse that can continuously and reversibly update its states. The device states are straightforwardly manifested in the form of variable output voltage, enabling large-scale direct cascading of multiple ferroelectric synapses to build a deep physical neural network. Such a neural network based on potential superposition rather than current flow is analogous to the biological counterpart driven by action potentials in the brain. A high accuracy of over 97% for the simulation of handwritten digit recognition is achieved using the voltage-mode neural network. The controlled ferroelectric polarization, revealed by piezoresponse force microscopy, turns out to be responsible for the synaptic weight updates in the ferroelectric synapses. The present work demonstrates an alternative strategy for the design and construction of emerging artificial neural networks.

Endoscopic management of postoperative fistulas using purse-string suture combined with cyanoacrylate.

A 65-year-old man complained of choking and hoarseness for fifteen days, and was diagnosed with thyroid carcinoma infiltrating esophagus and trachea. Therefore, the patient underwent thyroidectomy, partial esophagectomy, and partial tracheal resection, and histopathology confirmed primary squamous cell carcinoma of the thyroid. Unfortunately, on the tenth postoperative day, an esophagogastroduodenoscopy showed a large fistula (25 mm*20 mm) in esophageal introitus, and diagnosed with tracheoesophageal fistula due to sustained choking. The patient failed to response to conservative treatment within 14 days. Consequently, endoscopic management was performed that the fistula was partly closed by purse-string suture using endoloop and hemostatic clips, then 1 ml of cyanoacrylate (Compon, China) was injected into the fistulous tract through a catheter. Interestingly, the patient's symptom was relieved after the procedure. And, esophagogastroduodenoscopy revealed healing of the fistula 14 days later.

A small transparent cap, an extensive use.

A 92-year-old woman complained of dysphagia and vomit for 4 days without previous disease history. We use the transparent cap empty esophageal solid foods.

Endoscopic resection in combination with ligation for the treatment of duodenal subepithelial lesions: a single-center experience

Introduction and aim: duodenal subepithelial lesions (SELs) are increasingly detected during endoscopic examinations. However, no feasible and safe methods are available to remove duodenal SELs. The present study aimed to assess the feasibility and safety of endoscopic resection in combination with ligation (ER-L) for the removal of duodenal SELs.Patients and methods: a total of 101 patients with duodenal SELs underwent ER-L from February 2010 to February 2020. The primary outcomes were complete resection, en bloc resection and R0 resection. The secondary outcomes included procedure duration, bleeding, perforation and residual lesions. A total of 101 patients with 101 duodenal SELs (ranged from 8.4 mm to 20.2 mm in size) were included in the study.Results: most of the SELs (95.1 %) originated from the submucosal layer and were successfully removed using ER-L. The rates of complete resection, en bloc resection and R0 resection were 100 %, 96.0 % and 88.1 %, respectively. The median procedure duration was eight minutes. There were no severe complications, except for four patients who developed post-procedure bleeding (4.0 %) and recovered after conservative treatment. Furthermore, no residual lesions were detected during the follow-up period (median of 36 months). In fact, logistic regression analysis showed that the size of duodenal SELs was an independent factor for R0 resection during the ER-L procedure.Conclusion: in conclusion, ER-L is feasible and safe to remove duodenal SELs that originate from the submucosal layer and are less than 20 mm. However, the feasibility and safety of the ER-L should be further confirmed when removing the duodenal SELs that originate from the muscularis propria (MP) layer and are larger than 20 mm in diameter. (AU)

Comparison of Two Different Accesses Single Orifice Percutaneous Endoscopic Surgery in Diagnosis of Ascites of Unknown Origin: A Retrospective Study.

Background: Ascites is a common clinical finding caused by many different diseases, so we developed a technique termed single orifice percutaneous endoscopic surgery (SOPES) which can access peritoneal cavity through the contralateral McBurney's point or umbilicus to seek the underlying causes. In this study, we describe the initial clinical experience of SOPES and compare the application of two accesses. Methods: This is a retrospective study performed between 2007 and 2018. Patients with ascites of unknown origin who underwent these two kinds of SOPES were included. Main outcomes were measured by diagnostic accuracy, complication rate, procedure time, time till stitches removal, length of hospital stay, and hospital cost. Results: 148 patients successfully undergone SOPES via the contralateral McBurney's point (IM group, n = 70) or the umbilicus (UM group, n = 78). 63 patients in the IM group and 71 patients in the UM group reached clear diagnosis (90.0% vs. 91.0%, p = 0.831). The overall complication rate was 5.4%, while the UM group was higher than the IM group (10.3% vs. 0%, p = 0.017). All complications were resolved after medical treatment, and no mortality resulted from this procedure. The procedure time and the time until stitches removal in the UM group were longer than that in the IM group. There were no significant differences in length of hospital stay and hospital cost between the two groups. Conclusions: SOPES, which combines the strength of minimally invasive single orifice incision and flexible angles of examination and instrumentation, is a newly developed flexible endoscopic surgical modality that provides new important clinical valuable in evaluation of ascites of unknown origin. Moreover, SOPES via the contralateral McBurney's point was safer than the umbilicus approach.

Endoscopic resection in combination with ligation for the treatment of duodenal subepithelial lesions: a single-center experience.

INTRODUCTION AND AIM: duodenal subepithelial lesions (SELs) are increasingly detected during endoscopic examinations. However, no feasible and safe methods are available to remove duodenal SELs. The present study aimed to assess the feasibility and safety of endoscopic resection in combination with ligation (ER-L) for the removal of duodenal SELs. PATIENTS AND METHODS: a total of 101 patients with duodenal SELs underwent ER-L from February 2010 to February 2020. The primary outcomes were complete resection, en bloc resection and R0 resection. The secondary outcomes included procedure duration, bleeding, perforation and residual lesions. A total of 101 patients with 101 duodenal SELs (ranged from 8.4 mm to 20.2 mm in size) were included in the study. RESULTS: most of the SELs (95.1 %) originated from the submucosal layer and were successfully removed using ER-L. The rates of complete resection, en bloc resection and R0 resection were 100 %, 96.0 % and 88.1 %, respectively. The median procedure duration was eight minutes. There were no severe complications, except for four patients who developed post-procedure bleeding (4.0 %) and recovered after conservative treatment. Furthermore, no residual lesions were detected during the follow-up period (median of 36 months). In fact, logistic regression analysis showed that the size of duodenal SELs was an independent factor for R0 resection during the ER-L procedure. CONCLUSION: in conclusion, ER-L is feasible and safe to remove duodenal SELs that originate from the submucosal layer and are less than 20 mm. However, the feasibility and safety of the ER-L should be further confirmed when removing the duodenal SELs that originate from the muscularis propria (MP) layer and are larger than 20 mm in diameter.

Oral higher dose prednisolone to prevent stenosis after endoscopic submucosal dissection for early esophageal cancer.

BACKGROUND: Esophageal stenosis is one of the main complications of endoscopic submucosal dissection (ESD) for the treatment of large-area superficial esophageal squamous cell carcinoma and precancerous lesions (≥ 3/4 of the lumen). Oral prednisone is useful to prevent esophageal stenosis, but the curative effect remains controversial. AIM: To share our experience of the precautions against esophageal stenosis after ESD to remove large superficial esophageal lesions. METHODS: Between June 2019 and March 2022, we enrolled patients with large superficial esophageal squamous cell carcinoma and high-grade intraepithelial neoplasia experienced who underwent ESD. Prednisone (50 mg/d) was administered orally on the second morning after ESD for 1 mo, and tapered gradually (5 mg/wk) for 13 wk. RESULTS: In total, 14 patients met the inclusion criteria. All patients received ESD without operation-related bleeding or perforation. There were 11 patients with ≥ 3/4 and < 7/8 of lumen mucosal defects and 1 patient with ≥ 7/8 of lumen mucosal defect and 2 patients with the entire circumferential mucosal defects due to ESD. The longitudinal extension of the esophageal mucosal defect was < 50 mm in 3 patients and ≥ 50 mm in 11 patients. The esophageal stenosis rate after ESD was 0% (0/14). One patient developed esophageal candida infection on the 30th d after ESD, and completely recovered after 7 d of administration of oral fluconazole 100 mg/d. No other adverse events of oral steroids were found. CONCLUSION: Oral prednisone (50 mg/d) and prolonged prednisone usage time may effectively prevent esophageal stricture after ESD without increasing the incidence of glucocorticoid-related adverse events. However, further investigation of larger samples is required to warrant feasibility and safety.

Optimal Timing of Simethicone Supplement for Bowel Preparation: A Prospective Randomized Controlled Trial.

Background and Aims: Simethicone (SIM), as an antifoaming agent, has been shown to improve bowel preparation during colonoscopy. However, the optimal timing of SIM addition remained undetermined. We aimed to investigate the optimal timing of SIM addition to polyethylene glycol (PEG) to improve bowel preparation. Methods: Eligible patients were randomly assigned to two groups: the SIM evening group (SIM addition to PEG in the evening of the day prior to colonoscopy) and the SIM morning group (SIM addition to PEG in the morning of colonoscopy). The primary outcome was Bubble Scale (BS). The secondary outcomes were Boston Bowel Preparation Scale (BBPS) and adenoma detection rate (ADR). Results: A total of 419 patients were enrolled in this study. The baseline characteristics of the patients were similar in both groups. No significant differences were observed in terms of BS (8.76 ± 0.90 vs. 8.65 ± 1.16, P = 0.81), ADR (34.1% vs. 30.8%, P = 0.47), Boston Bowel Preparation Scale (BBPS) (8.59 ± 0.94 vs. 8.45 ± 1.00, P = 0.15), and withdrawal time (8.22 ± 2.04 vs. 8.01 ± 2.51, P = 0.094) between the two groups. Moreover, safety and compliance were similar in both groups. However, the SIM evening group was associated with shorter cecal intubation time (3.80 ± 1.81 vs. 4.42 ± 2.03, P < 0.001), higher BS (2.95 ± 0.26 vs. 2.88 ± 0.38, P = 0.04) in the right colon, and diminutive ADR (62.5% vs. 38.6%, P = 0.022) in the right colon, when compared to the SIM evening group. Conclusions: The SIM addition to PEG in the evening of the day prior to colonoscopy can shorten cecal intubation time and improve BS scores and diminutive ADR of the right colon compared with the SIM addition to PEG in the morning of colonoscopy in bowel preparation.

Colonic Epithelial PHLPP2 Deficiency Promotes Colonic Epithelial Pyroptosis by Activating the NF-κB Signaling Pathway.

BACKGROUND: Ulcerative colitis (UC) is a chronic inflammatory disease with increasing prevalence worldwide. Barrier defect in intestinal epithelial cells (IECs) is one of the main pathogeneses in UC. Pyroptosis is a programmed lytic cell death and is triggered by inflammatory caspases, while little is known about its role in UC. METHODS: Differentially expressed genes (DEGs) were identified by comparing UC patients with healthy controls from the GEO datasets. The candidate genes involved in pyroptosis were obtained, and the underlying molecular mechanism in the progression of UC was explored in vivo and in vitro. RESULTS: Pleckstrin homology domain leucine-rich repeat protein phosphatase 2 (PHLPP2), a protein phosphatase, was downregulated and involved in regulating inflammation-induced IEC pyroptosis by modulating the NF-κB signaling in UC through bioinformatics analysis. Moreover, we demonstrated that PHLPP2 was downregulated in UC patients and UC mice. Besides, we found that PHLPP2 depletion activated the NF-κB signaling and increased the expressions of caspase-1 P20, Gasdermin N, IL-18, and IL-1ß contributing to IEC pyroptosis and inflammation in UC mice. Furthermore, we found that PHLPP2-/- mice developed hypersensitivity to dextran sulfate sodium (DSS) treatment toward colitis showing activated NF-κB signaling and dramatically induced expressions of caspase-1 P20, Gasdermin N, IL-18, and IL-1ß. Mechanically, this inflammation-induced downregulation of PHLPP2 was alleviated by an NF-κB signaling inhibitor in intestinal organoids of PHLPP2-/- mice and fetal colonic cells. CONCLUSIONS: PHLPP2 downexpression activated the NF-κB signaling and promoted the IEC pyroptosis, leading to UC progression. Therefore, PHLPP2 might be an attractive candidate therapeutic target for UC.

Feasibility and Safety of Mark-Guided Submucosal Tunneling Endoscopic Resection for Treatment of Esophageal Submucosal Tumors Originating from the Muscularis Propria: A Single-Center Retrospective Study.

Background: Submucosal tunneling endoscopic resection (STER) has effectively removed esophageal submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. However, clinical failure and adverse events of STER remain concerned. In this study, we described a mark-guided STER (markings before creating entry point) and evaluated its feasibility and safety for esophageal SMTs originating from MP. Methods: Patients receiving the mark-guided STER from October 2017 to July 2020 were included and followed up (ranged from 3 to 30 months). The primary outcomes included complete resection, en bloc resection, and R0 resection rates. The secondary outcomes included procedure duration, main complication, and residual lesions. Results: A total of 242 patients with 242 SMTs (median diameter of 22 mm, ranging from 7 mm to 40 mm) received the mark-guided STER. The median procedure duration was 55 min (ranging from 35 min to 115 min). The complete resection, en bloc resection, and R0 resection rates were 100%, 98.3%, and 97.5%, respectively. The adverse event rate was 4.5%. However, there was no severe complication. No residual SMTs were detected during the follow-up period. Logistic regression demonstrated that the SMT size and procedure duration were independent factors associated with en bloc resection (P=0.02 and P=0.04, respectively). Moreover, logistic regression demonstrated that the SMT size was an independent risk factor for main complications (P=0.02). Conclusion: Mark-guided STER was feasible and safe to remove esophageal SMTs ≦40 mm. However, it is necessary to further verify the feasibility and safety for the esophageal SMTs >40 mm.

Curcumin ameliorates DSS­induced colitis in mice by regulating the Treg/Th17 signaling pathway.

Curcumin has a therapeutic effect on ulcerative colitis, but the underlying mechanism has yet to be elucidated. The aim of the present study was to clarify the possible mechanisms. Dextran sulfate sodium­induced colitis mice were treated with curcumin via gavage for 7 days. The effects of curcumin on disease activity index (DAI) and pathological changes of colonic tissue in mice were determined. Interleukin (IL)­6, IL­10, IL­17 and IL­23 expression levels were measured by ELISA. Flow cytometry was used to detect the ratio of mouse spleen regulatory T cells (Treg)/Th17 cells, and western blotting was used to measure the nuclear protein hypoxia inducible factor (HIF)­1α level. The results demonstrated that curcumin can significantly reduce DAI and spleen index scores and improve mucosal inflammation. Curcumin could also regulate the re­equilibration of Treg/Th17. IL­10 level in the colon was significantly increased, while inflammatory cytokines IL­6, IL­17 and IL­23 were significantly reduced following curcumin treatment. No significant difference in HIF­1α was observed between the colitis and the curcumin group. It was concluded that oral administration of curcumin can effectively treat experimental colitis by regulating the re­equilibration of Treg/Th17 and that the regulatory mechanism may be closely related to the IL­23/Th17 pathway. The results of the present study provided molecular insight into the mechanism by which curcumin treats ulcerative colitis.

The efficacy and safety of underwater endoscopic mucosal resection for ≥10-mm colorectal polyps: systematic review and meta-analysis.

BACKGROUND: Underwater endoscopic mucosal resection (UEMR) is a promising strategy for nonpedunculated colorectal polyp removal. However, the efficacy and safety of the technique for the treatment of ≥ 10-mm colorectal polyps remain unclear. We aimed to comprehensively assess the efficacy and safety of UEMR for polyps sized 10-19 mm and ≥ 20 mm. METHODS: PubMed, EMBASE, and the Cochrane Library databases were searched for relevant articles from January 2012 to November 2019. Primary outcomes were the rates of adverse events and residual polyps. Secondary outcomes were the complete resection, en bloc resection, and R0 resection rates. RESULTS: 18 articles including 1142 polyps from 1093 patients met our inclusion criteria. The overall adverse event and residual polyp rates were slightly lower for UEMR when removing colorectal polyps of 10-19 mm vs. ≥ 20 mm (3.5 % vs. 4.3 % and 1.2 % vs. 2.6 %, respectively). The UEMR-related complete resection rate was slightly higher for colorectal polyps of 10-19 mm vs. ≥ 20 mm (97.9 % vs. 92.0 %). However, the en bloc and R0 resection rates were dramatically higher for UEMR removal of polyps of 10-19 mm vs. ≥ 20 mm (83.4 % vs. 36.1 % and 73.0 % vs. 40.0 %, respectively). In addition, univariate meta-regression revealed that polyp size was an independent predictor for complete resection rate (P = 0.03) and en bloc resection (P = 0.01). CONCLUSIONS: UEMR was an effective and safe technique for the removal of ≥ 10-mm nonpedunculated colorectal polyps. However, UEMR exhibited low en bloc and R0 resection rates for the treatment of ≥ 20-mm polyps.