Early esophagus cancer segmentation from gastrointestinal endoscopic images based on U-Net++model

Automatic segmentation of early esophagus cancer(EEC)in gastrointestinal endoscopy(GIE)images is a critical and challenging task in clinical settings,which relies primarily on labor-intensive and time-consuming routines.EEC has often been diagnosed at the late stage since early signs of cancer are not obvious,resulting in low survival rates.This work proposes a deep learning approach based on the U-Net++method to segment EEC in GIE images.A total of 2690 GIE images collected from 617 patients at the Digestive Endoscopy Center,West China Hospital of Sichuan University,China,have been utilized.The experimental result shows that our proposed method achieved promising results.Furthermore,the comparison has been made between the proposed and other U-Net-related methods using the same dataset.The mean and standard deviation(SD)of the dice similarity coefficient(DSC),intersection over union(IoU),precision(Pre),and recall(Rec)achieved by the proposed framework were DSC(%)=94.62±0.02,IoU(%)=90.99±0.04,Pre(%)=94.61±0.04,and Rec(%)=95.00±0.02,respectively,outperforming the others.The proposed method has the potential to be applied in EEC automatic diagnoses.

Occurrence of Boerhaave's syndrome after diagnostic colonoscopy:what else can emergency physicians do?

Dear editor,Boerhaave’s syndrome is a barogenic tear of the esophagus,typically at the gastroesophageal junction,caused by a sudden increase in intraluminal pressure in the distal esophagus.[1]In recent years,the number of Boerhaave’s syndrome cases has increased,and a growing proportion of clinicians have recognized this rare but life-threatening disease.

Efficacy and safety of endoscopic submucosal tunnel dissection for superficial esophageal squamous cell carcinoma and precancerous lesions

AIM To evaluate the clinical outcomes of patients who underwent endoscopic submucosal tunnel dissection(ESTD) for esophageal squamous cell carcinoma(ESCC) and precancerous lesions.METHODS ESTD was performed in 289 patients. The clinical outcomes of the patients and pathological features of the lesions were retrospectively reviewed.RESULTS A total of 311 lesions were included in the analysis. The en bloc rate, complete resection rate, and curative resection rate were 99.04%, 81.28%, and 78.46%, respectively. The ESTD procedure time was 102.4 ± 35.1 min, the mean hospitalization time was 10.3 ± 2.8 d, and the average expenditure was 3766.5 ± 846.5 dollars. The intraoperative bleeding rate was 6.43%, the postoperative bleeding rate was 1.61%, the perforation rate was 1.93%, and the postoperative infection rate was 9.65%. Esophageal stricture and positive margin were severe adverse events, with an incidence rate of 14.79% and 15.76%, respectively. No tumor recurrence occurred during the follow-up period. CONCLUSION ESTD for ESCC and precancerous lesions is feasible and relatively safe, but for large mucosal lesions, the rate of esophageal stricture and positive margin is high.

Risk factors for Mallory-Weiss Tear during endoscopic submucosal dissection of superficial esophageal neoplasms

BACKGROUND Adverse events during endoscopic submucosal dissection(ESD)of superficial esophageal neoplasms,such as perforation and bleeding,have been welldocumented.However,the Mallory-Weiss Tear(MWT)during esophageal ESD remains under investigation.AIM To investigate the incidence and risk factors of the MWT during esophageal ESD.METHODS From June 2014 to July 2017,patients with superficial esophageal neoplasms who received ESD in our institution were retrospectively analyzed.The clinicopathological characteristics of the patients were collected.Patients were divided into an MWT group and non-MWT group based on whether MWT occurred during ESD.The incidence of MWTs was determined,and the risk factors for MWT were then further explored.RESULTS A total of 337 patients with 373 lesions treated by ESD were analyzed.Twenty patients developed MWTs during ESD(5.4%).Multivariate analysis identified that female sex(OR=5.36,95%CI:1.47-19.50,P=0.011)and procedure time longer than 88.5 min(OR=3.953,95%CI:1.497-10.417,P=0.005)were independent risk factors for an MWT during ESD.The cutoff value of the procedure time for an MWT was 88.5 min(sensitivity,65.0%;specificity,70.8%).Seven of the MWT patients received endoscopic hemostasis.All patients recovered satisfactorily without surgery for the laceration.CONCLUSION The incidence of MWTs during esophageal ESD was much higher than expected.Although most cases have a benign course,fatal conditions may occur.We recommend inspection of the stomach during and after the ESD procedure for timely management in cases of bleeding MWTs or even perforation outside of the procedure region.

Left atrial diameter and atrial fibrillation,but not elevated NT-proBNP,predict the development of pulmonary hypertension in patients with HFpEF

Background The determinants of pulmonary hypertension(PH)due to heart failure with preserved ejection fraction(HFpEF)have been poorly investigated in patients with cardiovascular diseases(CVD).Methods From July 12017 to March 312019,a total of 149 consecutive HFp EF patients hospitalized with CVD were enrolled in this prospective cross-sectional study.A systolic pulmonary artery pressure(PASP)>35 mm Hg estimated by echocardiography was defined as PH-HFp EF.Logistic regression was performed to establish predictors of PH in HFpEF patients.Results Overall,the mean age of participants was 72±11 years,and 74(49.7%)patients were females.A total of 59(39.6%)patients were diagnosed with PH-HFpEF by echocardiography.The left atrial diameter(LAD)was related to the ratio of the transmitral flow velocities/mitral annulus tissue velocities in early diastole(E/E’)and the left ventricular diameter in systole(LVDs).N-Terminal pro B-type natriuretic peptide(NT-proBNP)was not found to be associated with LAD and impaired diastolic or systolic function of the left ventricle.Multivariable logistic regression showed that atrial fibrillation(AF)increased the risk of PH-HFpEF incidence 3.46-fold with a 95%confidence interval(CI)of 1.44–8.32,P=0.005.Meanwhile,LAD≥45 mm resulted in a 3.43-fold increased risk,95%CI:1.51–7.75,P=0.003.However,the significance levels of NT-proBNP,age and LVEF were underpowered in the regression model.Two variables,AF and LAD≥45 mm,predicted the PH-HFpEF incidence(C-statistic=0.773,95%CI:0.695–0.852,P<0.001).Conclusions Two parameters associated with electrical and anatomical remodelling of the left atrium were related to the incidence of PH in HFpEF patients with CVD.

Risks of incident heart failure with preserved ejection fraction in Chinese patients hospitalized for cardiovascular diseases

Background Endogenous aldehyde damages DNA and potentiates an ageing phenotype. The aldehyde dehydrogenase 2(ALDH2) rs671 polymorphism has a prevalence of 30%–50% in Asian populations. In this study, we aimed to analyze risk factors contributing to the development of heart failure with preserved ejection fraction(HFpEF) along with the genetic exposure in Chinese patients hospitalized with cardiovascular diseases(CVD). Methods From July 2017 to October 2018, a total of 770 consecutive Chinese patients with normal left ventricular ejection fractions(LVEF) and established CVD(hypertension, coronary heart diseases, or diabetes) were enrolled in this prospective cross-sectional study. HFpEF was defined by the presence of at least one of symptom(dyspnoea and fatigue) or sign(rales and ankle swelling) related to heart failure;N-terminal pro-B-Type natriuretic peptide(NT pro-BNP ≥ 280 pg/mL);LVEF ≥ 50%;and at least one criterion related to elevated ventricular filling pressure or diastolic dysfunction(left atrial diameter > 40 mm, E/E’ ≥ 13, E’/A’ < 1 or concurrent atrial fibrillation). Logistic regression was performed to yield adjusted odds ratios(ORs) for HFp EF incidence associated with traditional and/or genetic exposures. Results Finally, among 770 patients with CVD, 92(11.9%) patients were classified into the HFpEF group according to the diagnostic criteria. The mean age of the participants was 67 ± 12 years, and 278(36.1%) patients were females. A total of 303(39.4%) patients were ALDH2*2 variant carriers. In the univariate analysis, eight exposures were found to be associated with HFpEF: atrial fibrillation, ALDH2*2 variants, hypertension, age, anaemia, smoking, alcohol consumption and sex. Multivariable logistic regression showed that 4 ‘A’ variables(atrial fibrillation, ALDH2*2 variants, age and anaemia) were significantly associated with an increased risk of HFpEF. Atrial fibrillation was associated with a 3.8-fold increased HFpEF risk(95% CI: 2.21–6.61, P < 0.001), and the other three exposures associated with increased HFpEF risk were the ALDH2*2 variant(OR = 2.41, 95% CI: 1.49–3.87, P < 0.001), age(OR = 2.14, 95% CI: 1.27–3.60, P = 0.004), and anaemia(OR = 1.79, 95% CI: 1.05–3.03, P = 0.032). These four variables predicted HFpEF incidence in Chinese CVD patients(C-statistic = 0.745, 95% CI: 0.691–0.800, P < 0.001). Conclusions 4 A traits(atrial fibrillation, ALDH2*2 variants, age and anaemia) were associated with an increased risk of HFpEF in Chinese CVD patients. Our results provide potential clues to the aetiology, pathophysiology and therapeutic targets of HFpEF.

Feasible endoscopic therapy for early gastric cancer

AIM: To analyze the relationship between lymph node metastasis and clinical pathology of early gastric cancer(EGC) in order to provide criteria for a feasible endoscopic therapy.METHODS: Clinical data of the 525 EGC patients who underwent surgical operations between January 2009 and March 2014 in the West China Hospital of Sichuan University were analyzed retrospectively. Clinical pathological features were compared between different EGC patients with or without lymph node metastasis, and investigated by univariate and multivariate analyses for possible relationships with lymph node metastasis.RESULTS: Of the 2913 patients who underwent gastrectomy with lymph node dissection, 529 cases were pathologically proven to be EGC and 525 cases were enrolled in this study, excluding 4 cases of gastric stump carcinoma. Among 233 patients with mucosal carcinoma, 43(18.5%) had lymph node metastasis. Among 292 patients with submucosal carcinoma, 118(40.4%) had lymph nodemetastasis. Univariate analysis showed that gender, tumor size, invasion depth, differentiation type and lymphatic involvement correlated with a high risk of lymph node metastasis. Multivariate analysis revealed that gender(OR = 1.649, 95%CI: 1.091-2.492, P = 0.018), tumor size(OR = 1.803, 95%CI: 1.201-2.706, P = 0.004), invasion depth(OR = 2.566, 95%CI: 1.671-3.941, P = 0.000), histological differentiation(OR = 2.621, 95%CI: 1.624-4.230, P = 0.000) and lymphatic involvement(OR = 3.505, 95%CI: 1.590-7.725, P = 0.002) wereindependent risk factors for lymph node metastasis. Comprehensive analysis showed that lymph node metastasis was absent in patients with tumor that was limited to the mucosa, size ≤ 2 cm, differentiated and without lymphatic involvement.CONCLUSION: We propose an endoscopic therapy for EGC that is limited to the mucosa, size ≤ 2 cm, differentiated and without lymphatic involvement.

Development and validation of a model to determine risk of refractory benign esophageal strictures

BACKGROUND Current research has identified several risk factors for refractory benign esophageal strictures (RBES), but research is scarce on the prediction of RBES in benign esophageal strictures patients. Meanwhile, the long-term outcomes of RBES remain unclear. The aim of this study was to develop and validate a model to determine the progression of RBES in patients with benign esophageal strictures. And we also explored the long-term outcomes and safety in patients with RBES. AIM To develop and validate a model to determine the progression of RBES in patients with benign esophageal strictures, based on the demographic data and endoscopic findings. METHODS A total of 507 benign esophageal stricture patients treated by dilation alone or in combination with stenting were retrospectively enrolled between January 2009 and February 2018. The primary outcome was to establish a risk-scoring model predicting RBES in benign esophageal strictures. The secondary outcome was to explore the clinical effectiveness and adverse events in patients with RBES. RESULTS In the study, age, etiology, and number and length of strictures were the independent risk factors for the refractory performance of benign esophageal strictures. According to risk factors of benign esophageal strictures, a risk-scoring model for predicting RBES in benign esophageal strictures was established: The risk score ranged from 0 to 8 points, and the risk scores were divided into low risk (0-2 points), intermediate risk (3-5 points), and high risk (6-8 points). The proportions of RBES in the corresponding risk categories were 1.0%, 12.2%, and 76.0%, respectively. Among 507 patients, 57 had RBES (39 males;median age, 60 years). The success rate of dilation treatment (51.2%, 21/41) was higher than that of stent placement (37.5%, 6/16). CONCLUSION In this study, 11.3%(57/507) patients had RBES at our hospital. The risk-scoring model predicting RBES in benign esophageal strictures could predict the longterm outcome of patients with strictures ahead.

Endoscopic submucosal tunnel dissection for early esophageal squamous cell carcinoma in patients with cirrhosis:A propensity score analysis

BACKGROUND Although early esophageal squamous cell carcinoma(EESCC)with cirrhosis is a relatively rare clinical phenomenon,the management of EESCC in cirrhotic patients continues to be a challenge.AIM To evaluate the feasibility,safety,efficacy and long-term survival outcomes of endoscopic submucosal tunnel dissection(ESTD)for treating EESCC in patients with cirrhosis.METHODS This was a single-center retrospective cohort study.We examined 590 EESCC patients who underwent ESTD between July 14,2014,and May 26,2021,from a large-scale tertiary hospital.After excluding 25 patients with unclear lesion areas or pathological results,the remaining 565 patients were matched at a ratio of 1:3 by using propensity score matching.A total of 25 EESCC patients with comorbid liver cirrhosis and 75 matched EESCC patients were ultimately included in the analysis.Parametric and nonparametric statistical methods were used to compare the differences between the two groups.The Kaplan–Meier method was used to create survival curves,and differences in survival curves were compared by the log-rank test.RESULTS Among 25 patients with liver cirrhosis and 75 matched noncirrhotic patients,there were no significant differences in intraoperative bleeding(P=0.234),30-d post-ESTD bleeding(P=0.099),disease-specific survival(P=0.075),or recurrence-free survival(P=0.8196).The mean hospitalization time and costs were significantly longer(P=0.007)and higher(P=0.023)in the cirrhosis group than in the noncirrhosis group.The overall survival rate was significantly lower in the cirrhosis group(P=0.001).CONCLUSION ESTD is technically feasible,safe,and effective for patients with EESCC and liver cirrhosis.EESCC patients with Child-Pugh A disease seem to be good candidates for ESTD.

Intestinal histoplasmosis in immunocompetent adults

AIM: To present a retrospective analysis of clinical and endoscopic features of 4 cases of immunocompetent hosts with intestinal histoplasmosis(IH).METHODS: Four immunocompetent adults were diagnosed with IH between October 2005 and March 2015 at West China Hospital of Sichuan University. Clinical and endoscopic characteristics were summarized and analyzed retrospectively. GMS(Gomori methenamine silver), PAS(periodic acid-Schiff) and Giemsa staining technique were used to confirm Histoplasma capsulatum(H. capsulatum). The symptoms, signs, endoscopic presentations, radiographic imaging, pathological stain results and follow-up are presented as tables and illustrations.RESULTS: The cases were male patients, ranging from 33 to 61 years old, and primarily presented with nonspecific symptoms such as irregular fever, weight loss, abdominal pain and distention. Hepatosplenomegaly and lymphadenopathy were the most common signs. Endoscopic manifestations were localized or diffuse congestion, edema, ulcers, and polypoid nodules with central erosion involving the terminal ileum, ascendingcolon, transverse colon, descending colon, sigmoid colon and rectum, similar to intestinal tuberculosis, tumor, and inflammatory bowel disease. Numerous yeast-like pathogens testing positive for PAS and GMS stains but negative for Giemsa were detected in the cytoplasm of the histiocytes, which were highly suggestive of H. capsulatum.CONCLUSION: Immunocompetent individuals suffering from histoplasmosis are rarely reported. It is necessary that gastroenterologists and endoscopists consider histoplasmosis as a differential diagnosis, even in immunocompetent patients.

Noncirrhotic portal hypertension due to peripheral T-cell lymphoma,not otherwise specified:A case report

BACKGROUND Peripheral T-cell lymphoma(PTCL),an aggressive and rare disease that belongs to a heterogeneous group of mature T-cell lymphomas,develops rapidly and has a poor prognosis.Early detection and treatment are essential to improve patient cure and survival rates.Here,we report a rare case of PTCL with clinical presentation of noncirrhotic portal hypertension,which provides a basis for early vigilance of lymphomas in the future.CASE SUMMARY A 65-year-old Chinese woman was admitted to our hospital because of abdominal distension for 3 months and pitting oedema of both lower limbs for 2 months.Physical examinations and associated auxiliary examinations showed the presence of hepatosplenomegaly,and her hepatic venous pressure gradient was 10 mmHg.Immunohistochemical analysis of the liver biopsy confirmed the diagnosis of PTCL.The patient underwent combination therapy with dexamethasone,VP-16,and chidamide.Unfortunately,after 41 days of chemotherapy,the patient died of multiple organ failure.CONCLUSION PCTL accompanied by noncirrhotic portal hypertension is rarely reported.This case report discusses the diagnosis of a patient according to the literature.

Quantitative Evaluation of the Compatibility Effects of Aidi Injection on the Treatment of Hepatocellular Carcinoma Using Targeted Metabolomics:A New Strategy on the Mechanism Study of an Anticancer Compound in Traditional Chinese Medicine

Objective:Compound traditional Chinese medicine(CTCM)with the application of compatibility from multiple active ingredients with multiple-specific targets can achieve a synergistic effect on cancer therapy.This study is aimed to observe the compatibility effects of Aidi injection on the treatment of hepatocellular carcinoma and to explore the mechanism of CTCM.Methods:Aidi injection is a clinical compound prescription containing Mylabris,Ginseng,Astragalus,and Acanthopanax,which can inhibit tumor growth and induce apoptosis.In this study,the anticancer activity of Aidi injection,as well as its disassembled and combined compositions,had been evaluated by varying levels of polyamine biomarkers on human hepatoma Hep-G2 cells detected using ultrahigh-performance liquid chromatography-tandem mass spectrometry.Results:According to the different variations in polyamine levels,it was revealed that Mylabris and Ginseng had an antitumor effect,while Astragalus acted as an assistant and Acanthopanax had weak anticancer activity.The increased level of polyamines in Hep-G2 cells had been found in HL-7702 cells.On combining Mylabris and Ginseng,polyamine levels went close to the normal level,which was even more marked when Astragalus was added.Aidi injection acted like the combination of Mylabris,Ginseng,and Astragalus.Conclusions:This study established a quantitative evaluation of the compatibility effects of Aidi injection based on polyamine biomarkers and evaluated the consistency of its anticancer effect,providing a manner to research the efficacy evaluation of CTCM.Moreover,the correlation between polyamine metabolism and anticancer activity can be used in anticancer drug screening.