Recanalization of anastomotic occlusion following rectal cancer surgery using a rendezvous endoscopic technique with transillumination:A case report

BACKGROUND Colorectal anastomotic occlusion is a serious complication of colorectal cancer surgery.Although several treatment strategies have been proposed,the mana-gement of anastomotic occlusion remains challenging.In this report,we present a case of anastomotic occlusion recanalization performed using a novel technique involving two endoscopes,one for radial incision and the other serving as a guide light.This novel technique offers significant advantages in terms of operational feasibility,reduced invasiveness,rapid recovery,and shortened hospital stay.CASE SUMMARY A 37-year-old man underwent low anterior resection and prophylactic double-lumen ileostomy for rectal cancer in June,2023.Two months later,complete anastomotic occlusion was observed on colonoscopy.Therefore,we developed a novel atresia recanalization technique.Two endoscopes were placed,one through the colonic anastomosis and the other through the anus.A radial incision was successfully made from the colonic side,guided by the light of the endoscope from the anal side.Atresia recanal-ization was performed within 20 minutes.Three weeks after recanalization,colonoscopy revealed that the diameter of the colorectal anastomosis was approximately 16 mm and the patient therefore underwent stoma reversal in September.During the follow-up period of approximately one year,the patient remained well and no stenosis or obstruction symptoms were observed.CONCLUSION Endoscopic atresia recanalization of colorectal anastomotic occlusion assisted by an opposing light source is safe and effective.

Evaluation of preoperative staging for esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma(ESCC) is known for its rapid progression and poor outcomes. China has the highest incidence and mortality in the world. Diagnoses made at early stages and accurate staging are associated with better outcomes, all of which can play a significant role in the selection of treatment protocols. ESCC is staged according to the widely accepted TNM system. Common imaging modalities used in staging ESCC before treatment include endoscopy, computed tomography(CT), positron emission tomography(PET) and magnetic resonance imaging(MRI). Endoscopic ultrasound is useful for staging tumor depth and nodal status. Narrow band imaging is valuable for early stage disease assessment. CT and PET provide additional valuable information regarding node and metastasis staging. The ability of MRI to delineate ESCC is continuously being improved and adds information regarding locoregional status to routine examinations.

Concurrent chemoradiotherapy combined with enteral nutrition support:a radical treatment strategy for esophageal squamous cell carcinoma patients with malignant istulae

Background: Concurrent chemoradiotherapy(CCRT) significantly increases the survival rate of esophageal squa?mous cell carcinoma(ESCC) patients with malignant fistulae. Recent clinical evidence has shown the benefits of enteral nutrition for malnourished cancer patients. In this study, we aimed to validate that, with the support of enteral nutrition, ESCC patients who develop malignant fistulae might be able to complete CCRT and achieve long?term survival.Methods: We reviewed the medical records of 652 patients with ESCC who received definitive CCRT at Sun Yat?sen University Cancer Center between January 2010 and December 2012. Treatment outcome and toxicity were ret?rospectively evaluated in 40 ESCC patients with malignant fistulae. All the 40 patients were treated with CCRT and evaluated by clinical nutritionists using nutrition risk screening(NRS) before, during, and after treatment. Twenty?two patients received a nasogastric tube, and 18 underwent percutaneous endoscopic gastrostomy feeding. The median energy intake was 2166 kcal/day. Treatment response was evaluated at 3 months after the completion of CCRT.Results: With a median follow?up of 18 months(range, 3–39 months), patients' 1?year overall survival(OS) rate was 62.5%, and the estimated OS time was 25.5 months. Univariate analysis showed that the NRS score(P n NRS score(P se to treatment(P < 0.001) were sig= 0.003), increase i= 0.024), fistula closure(P = 0.011), and responnifi?cantly associated with OS. Multivariate analysis showed that tumor response(P = 0.044) and increase in NRS score(P = 0.044) were independent predictors of OS. Grade 3 vomiting was observed in 8 patients(20.0%), grade 3 neutro?penia was observed in 11 patients(27.5%), and grade 3 cough was observed in 13 patients(32.5%); 2 patients(5.0%) died of massive bleeding during treatment.Conclusions: CCRT combined with enteral nutrition support is effective for ESCC patients with malignant fistulae. Patients have an increased potential to be cured, especially those who experience complete response and have an increase in NRS score. Careful observation and nutrition support are required for patients with advanced T?category ESCC who undergo CCRT.

Complications of high intensity focused ultrasound in patients with recurrent and metastatic abdominal tumors

AIM： To analyze the local and systemic complications of high intensity focused ultrasound （HIFU） for patients with recurrent and metastatic abdominal tumors. METHODS： From Aug 2001 to Aug 2004, 17 patients with recurrent and metastatic abdominal tumors were enrolled in this study. Real-time sonography was taken, and vital signs, liver and kidney function, skin burns, local reactions, and systemic effects were observed and recored before, during, and after HIFU. CT and MR/were also taken before and after HIFU. RESULTS： All 17 patients had skin burns and pain in the treatment region; the next common complication was neurapraxia of the stomach and intestines to variable degrees. The other local and systemic complications were relatively rare. Severe complications were present in two patients; one developed a superior mesenteric artery infarction resulting in necrosis of the entire small intestines, and the other one suffered from a perforation in terminal ileum due to HIFU treatment. CONCLUSION： Although HIFU is a one of noninvasive treatments for the recurrent and metastatic abdominal tumors, there are still some common and severe complications which need serious consideration.

Primary intestinal non-Hodgkin's lymphoma:A clinicopathologic analysis of 81 patients

AIM:To analyze the clinicopathologic features and the prognosis of primary intestinal lymphoma.METHODS:Patients were included in the study based on standard diagnostic criteria for primary gastrointesti-nal lymphoma,and were treated at Sun Yat-sen Univer-sity Cancer Centre between 1993 and 2008.RESULTS:The study comprised 81 adults.The most common site was the ileocaecal region.Twenty-two point two percent patients had low-grade B-cell lym-phoma.Fifty-one point nine percent patients had high-grade B-cell lymphoma and 25.9% patients had T-cell lymphoma.Most patients had localized disease.There were more patients and more early stage diseases in the latter period,and the origin sites changed.The ma-jority of patients received the combined treatment,andabout 20% patients only received nonsurgical therapy.The wverall survival and event-free survival rates after 5 years were 71.6% and 60.9% respectively.The mul-tivariate analysis revealed that small intestine and ileo-caecal region localization,B-cell phenotype,and normal lactate dehydrogenase were independent prognostic factors for better patient survival.Surgery based treat-ment did not improve the survival rate.CONCLUSION:Refined stratification of the patients according to the prognostic variables may allow indi-vidualized treatment.Conservative treatment may be an optimal therapeutic modality for selected patients.

Endoscopic ultrasonography for staging of T1a and T1b esophageal squamous cell carcinoma

AIM: To investigate the accuracy of Endoscopic ultrasound (EUS) in staging and sub-staging T1a and T1b esophageal squamous cell carcinoma (ESCC).

Study of preoperative diagnostic modalities in Chinese patients with superficial esophageal squamous cell carcinoma

BACKGROUND Endoscopic ultrasonography(EUS)and magnifying endoscopy(ME)reliably determine indications for endoscopic resection in patients with superficial esophageal squamous cell carcinoma(SESCC).ME is widely accepted for predicting the invasion depth of superficial esophageal cancer with satisfying accuracy.However,the addition of EUS is controversial.AIM To evaluate the diagnostic efficiency of ME vs EUS for invasion depth prediction and investigate the influencing factors in patients with SESCC to determine the best diagnostic model in China.METHODS We retrospectively analyzed patients with suspected SESCC who completed both ME and EUS and then underwent endoscopic or surgical resection at Sun Yat-Sen University Cancer Center between January 2018 and December 2021.We evaluated and compared the diagnostic efficiency of EUS and ME according to histological results,and investigated the influencing factors.RESULTS We included 152 lesions from 144 patients in this study.The diagnostic accuracies of ME and EUS in differentiating invasion depth were not significantly different(73.0%and 66.4%,P=0.24);both demonstrated moderate consistency with the pathological results(ME:kappa=0.58,95%confidence interval[CI]:0.48-0.68,P<0.01;EUS:kappa=0.46,95%CI:0.34-0.57,P<0.01).ME was significantly more accurate in the diagnosis of high-grade intraepithelial(HGIN)or carcinoma in situ(odds ratio[OR]=3.62,95%CI:1.43-9.16,P=0.007)subgroups.Using a miniature probe rather than conventional EUS can improve the accuracy of lesion depth determination(82.3%vs 49.3%,P<0.01).Less than a quarter of circumferential occupation and application of a miniature probe were independent risk factors for the accuracy of tumor invasion depth as assessed by EUS(<1/4 circumferential occupation:OR=3.07,95%CI:1.04-9.10;application of a miniature probe:OR=5.28,95%CI:2.41-11.59,P<0.01).Of the 41 lesions(41/152,27.0%)that were misdiagnosed by ME,24 were corrected by EUS(24/41,58.5%).CONCLUSION Preoperative diagnosis of SESCC should be conducted endoscopically using white light and magnification.In China,EUS can be added after obtaining patient consent.Use of a highfrequency miniature probe or miniature probe combined with conventional EUS is preferable.

Methyl-methanesulfonate sensitivity 19 expression is associated with metastasis and chemoradiotherapy response in esophageal cancer

AIM: To investigate the clinical significance of methylmethanesulfonate sensitivity 19(MMS19) expression in esophageal squamous cell carcinoma(ESCC).METHODS: Between June 2008 and May 2013, specimens from 103 patients who underwent endoscopic biopsy for the diagnosis of ESCC at the endoscopy center of Sun Yat-Sen University Cancer Center were collected; 52 matched-normal esophageal squamous epithelium samples were biopsied as controls.MMS19 protein expression was measured by immunohistochemistry.Of the 103 cases of ESCC, 49 received radical surgery following neoadjuvant chemoradiotherapy consisting of concurrent radiation in a total dose of 40 Gy and two cycles of chemotherapy with vinorelbine and cisplatin.Relationships between MMS19 expression, clinicopathologic characteristics and chemoradiotherapy response were analyzed.RESULTS: The MMS19 protein could be detected in both the cytoplasm and nucleus of most specimens.High cytoplasmic expression of MMS19 was detected in 63.1% of ESCC samples, whereas high nuclearexpression of MMS19 was found in 35.0%.High cytoplasmic MMS19 expression was associated with regional lymph node metastases(OR = 11.3, 95%CI: 2.3-54.7; P < 0.001) and distant metastases(OR = 13.1, 95%CI: 1.7-103.0; P = 0.002).Furthermore, high cytoplasmic MMS19 expression was associated with a response of ESCC to chemoradiotherapy(OR = 11.5, 95%CI: 3.0-44.5; P < 0.001), with a high cytoplasmic MMS19 expression rates in 79.3% and 25.0% of patients from the good chemoradiotherapy response group and poor response group, respectively.Nuclear MMS19 expression did not show any significant association with clinicopathologic characteristics or chemoradiotherapy response in ESCC.CONCLUSION: The results of our preliminary study suggest that MMS19 may be a potential new predictor of metastasis and chemoradiotherapy response in ESCC.

同步放化疗联合肠内营养支持:食管鳞状细胞癌合并恶性瘘患者的根治策略

背景与目的同步放化疗(concurrent chemoradiotherapy,CCRT)可显著提高食管鳞状细胞癌(esophageal squamous cell carcinoma,ESCC)合并恶性瘘患者的生存率。最近的临床证据已经表明营养不良患者可从肠内营养中获益。本研究旨在验证在肠内营养支持下,发生恶性瘘的ESCC患者可能完成CCRT,并获得长期生存。方法我们回顾了2010年1月至2012年12月在中山大学肿瘤防治中心接受根治性CCRT的652例ESCC患者的病历。回顾性评价了40例食管癌合并恶性瘘患者的治疗结局及毒副反应。40例患者均接受了CCRT治疗,治疗前、中、后由临床营养师进行营养风险筛查(nutrition risk screening,NRS)评价。22例患者接受鼻胃管,18例接受经皮内镜胃造瘘术营养支持。中位能量摄入量为2166 kcal/d。在CCRT完成后的第3个月进行治疗反应评估。结果中位随访时间为18个月(范围:3–39个月),患者1年总生存(overall survival,OS)率为62.5%,估计OS的时间为25.5个月。单因素分析显示,NRS评分(P=0.003)、NRS评分增加(P=0.024)、瘘闭合(P=0.011)、治疗反应(P <0.001)与OS显著相关。多因素分析显示肿瘤反应(P=0.044)和NRS评分增加(P=0.044)是OS的独立预后因素。观察到3级呕吐8例(20.0%),3级中性粒细胞减少症11例(27.5%),3级咳嗽13例(32.5%),治疗期间死于大出血2例(5.0%)。结论 CCRT联合肠内营养支持治疗ESCC合并恶性瘘患者是有效的;患者治愈机会增加,尤其是那些完全缓解并表现NRS评分增加的患者。需要对接受CCRT的T分期较晚ESCC患者仔细观察和营养支持。

鼻咽癌放疗后内镜超声引导下咽后淋巴结细针抽吸术:一种新型准确诊断技术

背景与目的鼻咽癌(nasopharyngeal carcinoma,NPC)患者接受放射治疗后普遍出现咽后淋巴结(retropharyngeal lymph nodes,RLNs)增大。病理学检查结果决定了对增大RLNs最佳治疗方案的选择。然而,在临床上RLN取样难度大。我们最近开发了一种内镜超声引导下细针抽吸(endoscopic ultrasound-guided fine needle aspiration,EUS-FNA)的新型微创技术,可取到足够的RLN组织用以病理学或细胞学诊断。方法纳入30例经核磁共振成像(magnetic resonance imaging,MRI)检测疑似放疗后出现RLN转移的NPC患者。EUS探头经鼻孔置入鼻咽,然后使用EUS扫描咽后间隙并在颈动脉鞘前定位RLN,随后进行EUS-FNA。对EUS-FNA法从RLN组织取样的安全性和有效性进行评估。结果采用EUS-FNA法成功地对所有患者进行了组织取样。在30例患者中,23例经1次EUS-FNA取样后通过病理学或细胞学检查确认了活检组织中存在癌细胞。有7例患者经1次EUS-FNA活检后未确认存在癌细胞,随后再次采用EUS-FNA活检重新分析,又有2例被确认存在癌细胞;另外5例未确认存在癌细胞的患者密切随访3个月,每月进行1次MRI。随访3个月后,3例患者由于RLNs直径保持稳定或减小而被认为未患肿瘤;剩余2例表现出疾病进展的患者进行了第3次EUS-FNA活检,进一步确认为癌细胞阳性。本文所报道的整个队列中,EUS-FNA过程无任何严重并发症发生。结论采用EUS-FNA法对疑似NPC复发患者的RLNs取样是一种安全有效的诊断方法。

Extraesophageal saline enhances endoscopic ultrasonography to differentiate esophagus and adjacent organs

AIM: To distinguish between the esophagus and adjacent organs using extraesophageal saline injection (ESI) in a canine model.

Superficial esophageal lesions detected by endoscopic ultrasound enhanced with submucosal edema

AIM:To determine if there is consistency between endoscopic ultrasound(EUS)findings and pathological results for detecting lesions of different depth in the esophageal mucosa.METHODS:A canine(Beagle)model was established in which lesions of different depths were created in the esophageal mucosa by thermal burning.Seventy-two hours later,these lesions and adjacent tissue in the esophagus were examined by EUS.EUS findings including infiltrating depth,strength of echogenicity and homogeneity were recorded.Dogs were sacrificed and tissue specimens were obtained.We then compared the EUS findings with the pathology reports.RESULTS:Thermal burns created at different power settings caused lesions of different depth in the esophageal mucosa.When the echo strength was shifted from high,medium,to low echogenicity,an increase in the infiltrating depth of the lesion was noted,which coincided with results of the pathology examination.Obvious submucosal edema visualized by EUS was also detected by pathology.Furthermore,because of the enhancement caused by the submucosal edema,the lesions invading into the submucosa were easily visualized by EUS.CONCLUSION:There is consistency between EUS findings and pathological results of esophageal lesions with different depths.Submucosal edema can serve as an ultrasonic contrast agent.

Ultrasound-guided fine needle aspiration of retropharyngeal lymph nodes after radiotherapy for nasopharyngeal carcinoma: a novel technique for accurate diagnosis

Background:Enlarged retropharyngeal lymph nodes(RLNs)are very common in patients with nasopharyngeal carcinoma(NPC)undergoing radiotherapy.The most suitable treatment option for enlarged RLNs depends on the pathological results.However,RLN sampling is difficult and imminent in the clinic setting.We recently developed a novel minimally invasive technique termed endoscopic ultrasound-guided fine needle aspiration(EUS-FNA)for sam-pling RLN tissues sufficient for pathological or cytological diagnosis.Methods:We enrolled 30 post-radiotherapy patients with NPC with suspected RLN metastasis detected via mag-netic resonance imaging(MRI).The EUS probe was introduced into the nasopharynx via the nostrils,and EUS was then used to scan the retropharyngeal space and locate the RLN in the anterior carotid sheath.EUS-FNA was subsequently performed.The safety and efficacy of using EUS-FNA to sample the RLN tissues were assessed.Results:Strips of tissue were successfully sampled from all patients using EUS-FNA.Of the 30 patients,23 were confirmed to have cancer cells in the biopsied tissues via pathology or cytology examinations with 1 EUS-FNA biopsy session.The seven cases without confirmed cancer cells were subsequently reanalyzed by using another EUS-FNA biopsy session,and two more cases were confirmed possessing cancer cells.The other five patients without con-firmed cancer cells were closely followed with MRI every month for 3 months.After follow-up for 3 months,three patients were still considered cancer-free due to the presence of RLNs with stable or shrinking diameters.The rest two patients who showed progressive disease underwent a third EUS-FNA biopsy procedure and were further confirmed to be cancer cell-positive.In the whole cohort reported here,the EUS-FNA procedure was not associated with any severe complications.Conclusion:EUS-FNA is a safe and effective diagnostic approach for sampling tissues from the RLNs in patients with suspected recurrent NPC.