Risk factors for complications associated with upper gastrointestinal foreign bodies

AIM: To investigate predictive risk factors associated with complications in the endoscopic removal of foreign bodies from the upper gastrointestinal tract.METHODS: We retrospectively reviewed the medical records of 194 patients with a diagnosis of foreign body impaction in the upper gastrointestinal tract,confirmed by endoscopy,at two university hospital in South Korea.Patient demographic data,including age,gender,intention to ingestion,symptoms at admission,and comorbidities,were collected.Clinical features of the foreign bodies,such as type,size,sharpness of edges,number,and location,were analyzed.Endoscopic data those were analyzed included duration of foreign body impaction,duration of endoscopic performance,endoscopic device,days of hospitalization,complication rate,30-d mortality rate,and the number of operationsrelated to foreign body removal.RESULTS: The types of upper gastrointestinal foreign bodies included fish bones,drugs,shells,meat,metal,and animal bones.The locations of impacted foreign bodies were the upper esophagus(57.2%),mid esophagus(28.4%),stomach(10.8%),and lower esophagus(3.6%).The median size of the foreign bodies was 26.2 ± 16.7 mm.Among 194 patients,endoscopic removal was achieved in 189,and complications developed in 51 patients(26.9%).Significant complications associated with foreign body impaction and removal included deep lacerations with minor bleeding(n = 31,16%),ulcer(n = 11,5.7%),perforation(n = 3,1.5%),and abscess(n = 1,0.5%).Four patients underwent operations because of incomplete endoscopic foreign body extraction.In multivariate analyses,risk factors for endoscopic complications and failure were sharpness(HR = 2.48,95%CI: 1.07-5.72; P = 0.034) and a greater than 12-h duration of impaction(HR = 2.42,95%CI: 1.12-5.25,P = 0.025).CONCLUSION: In cases of longer than 12 h since foreign body ingestion or sharp-pointed objects,rapid endoscopic intervention should be provided in patients with ingested foreign bodies.

Endoscopic features suggesting gastric cancer in biopsy-proven gastric adenoma with high-grade neoplasia

AIM:To elucidate the endoscopic features that predict the cancer following endoscopic submucosal dissection(ESD)in patients with high-grade neoplasia(HGN).METHODS:We retrospectively analyzed the medical records of patients who underwent ESD of gastric neoplasms from January 2007 to September 2010.ESD was performed in 555 cases involving 550 patients.A total of 112 lesions from 110 consecutive patients were initially diagnosed as HGN without cancer by forceps biopsy,and later underwent ESD.We classified lesions into two groups according to histologic discrepancies between the biopsy and ESD diagnosis.Gastric adenoma in the final diagnosis by ESD specimens were defined as adenoma group.Lesions with coexisting cancer after ESD were defined as cancer group.RESULTS:The mean age was 65.3 years,and 81 patients were male.There was no significant difference in the age or gender distribution between the adenoma(n=52)and cancer(n=60)groups.Thirty-six of these lesions(32.1%)showed histologic concordance between the forceps biopsy and ESD specimens,16(14.3%)showed a downgraded histology(low-grade neoplasia),and 60(53.6%)showed an upgraded histology(cancer).A red color change of the mucosal surface on endoscopy was found in 27/52(51.9%)of cases in the adenoma group and in 46/60(76.7%)of cases in the cancer group(P=0.006).Ulceration of the mucosal surface on endoscopy was found in 5(9.6%)of 52 lesions in the adenoma group and in 17(28.3%)of 60 lesions in the cancer group(P=0.013).In the multivariate analysis,a reddish surface color change and mucosal ulceration were significant predictive factors correlated with cancer after ESD of the HGN by forceps biopsy.CONCLUSION:HGN with a red color change or mucosal ulceration correlated with the presence of gastric cancer.These finding may help to guide the diagnosis and treatment.

Stents for colorectal obstruction:Past,present,and future

Since the development of uncovered self-expanding metal stents(SEMS) in the 1990 s, endoscopic stents have evolved dramatically. Application of new materialsand new designs has expanded the indications for enteral SEMS. At present, enteral stents are considered the first-line modality for palliative care, and numerous types of enteral stents are under development for extended clinical usage, beyond a merely palliative purpose. Herein, we will discuss the current status and the future development of lower enteral stents.

Management of complications following endoscopic submucosal dissection for gastric cancer

Endoscopic treatment should be considered for early gastric cancer(EGC)and gastric precancerous lesions.Endoscopic submucosal dissection(ESD)was developed for en bloc removal of a large gastric neoplasm and has been developed following improvements in electrical equipment for hemostasis and dissection and with advances in various knives,hemostatic forceps and endoscopic equipment.ESD is currently the treatment of choice for precancerous lesions or EGC showing mucosal invasion.Hemorrhage and perforation are major complications of ESD for EGC.We describe the complication of ESD procedures in gastric lesions for endoscopists who are relatively inexperienced in ESD and who may lack optimal access to ESD education and facilities.

Anti-inflammatory and anti-apoptotic effects of rosuvastatin by regulation of oxidative stress in a dextran sulfate sodium-induced colitis model

AIM To evaluate the anti-inflammatory and anti-apoptotic effects of rosuvastatin by regulation of oxidative stress in a dextran sulfate sodium(DSS)-induced colitis model.METHODS An acute colitis mouse model was induced by oral administration of 5% DSS in the drinking water for 7 d. In the treated group, rosuvastatin(0.3 mg/kg per day) was administered orally before and after DSS administration for 21 d. On day 21, mice were sacrificed and the colons were removed for macroscopic examination, histology, and Western blot analysis. In the in vitro study, IEC-6 cells were stimulated with50 ng/m L tumor necrosis factor(TNF)-α and then treated with or without rosuvastatin(2 μmol/L). The levels of reactive oxygen species(ROS), inflammatory mediators, and apoptotic markers were measured. RESULTS In DSS-induced colitis mice, rosuvastatin treatment significantly reduced the disease activity index and histological damage score compared to untreated mice(P < 0.05). Rosuvastatin also attenuated the DSSinduced increase of 8-hydroxy-2'-deoxyguanosine and NADPH oxidase-1 expression in colon tissue. Multiplex ELISA analysis revealed that rosuvastatin treatment reduced the DSS-induced increase of serum IL-2, IL-4, IL-5, IL-6, IL-12 and IL-17, and G-CSF levels. The increased levels of cleaved caspase-3, caspase-7, and poly(ADP-ribose) polymerase in the DSS group were attenuated by rosuvastatin treatment. In vitro, rosuvastatin significantly reduced the production of ROS, inflammatory mediators and apoptotic markers in TNF-α-treated IEC-6 cells(P < 0.05).CONCLUSION Rosuvastatin had the antioxidant, anti-inflammatory and anti-apoptotic effects in DSS-induced colitis model. Therefore, it might be a candidate anti-inflammatory drug in patients with inflammatory bowel disease.

Dexamethasone inhibits hypoxia-induced epithelial-mesenchymal transition in colon cancer

AIM:To elucidate the effects of dexamethasone on hypoxia-induced epithelial-to-mesenchymal transition(EMT) in colon cancer.METHODS:Human colon cancer HCT116 and HT29 cells were exposed to normoxic(21%) and hypoxic(1%) conditions. First,the effect of dexamethasone on cell viability was examined by MTT cell proliferation assay. In order to measure the expression levels of EMT markers(Snail,Slug,Twist,E-cadherin,and integrin αVβ6) and hypoxia-related genes [Hypoxia-inducible factor-1α(HIF-1α) and vascular endothelial growth factor(VEGF)] by dexamethasone,quantitative real-time polymerase chain reaction and western blot analysis were performed. Furthermore,the morphological changes of colon cancer cells and the expression pattern of E-cadherin by dexamethasone were detected through immunocytochemistry. Finally,the effects of dexamethasone on the invasiveness and migration of colon cancer cells were elucidated using matrigel invasion,migration,and wound healing migration assays.RESULTS:Under hypoxia,dexamethasone treatment inhibited HIF-1α protein level and its downstream gene,VEGF m RNA level in the colon cancer cell lines,HCT116 and HT29. In addition,the presence of dexamethasone down-regulated the m RNA levels of hypoxia-induced Snail,Slug,and Twist,all transcriptional factors of EMT,as well as hypoxia-induced integrin αVβ6 protein level,a well-known EMT marker for colon cancer cells. Furthermore,reduced E-cadherin in hypoxic condition was found to be recoverable by treating with dexamethasone in both colon cancer cell lines. Similarly,under hypoxic conditions,dexamethasone restored the growth pattern and morphological phenotype reminiscent of colon cancer cells grown under normoxic conditions; dexamethasone blocked the migration and invasion of both colorectal cancer cell lines in hypoxia.CONCLUSION:Our study suggested that dexamethasone has inhibitory effects on cell migration and invasion by suppressing EMT of colon cancer cell lines in hypoxic condition.

Surgical failure after colonic stenting as a bridge to surgery

AIM: To identify risk factors for surgical failure after colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction.METHODS: The medical records of patients who underwent stent insertion for malignant colonic obstruction between February 2004 and August 2012 were retrospectively reviewed. Patients with malignant colonic obstruction had overt clinical symptoms and signs of obstruction. Malignant colonic obstruction was diagnosed by computed tomography and colonoscopy. A total of 181 patients underwent stent insertion during the study period; of these, 68 consecutive patientswere included in our study when they had undergone stent placement as a bridge to surgery in acute leftsided malignant colonic obstruction due to primary colon cancer.RESULTS: Out of 68 patients, forty-eight(70.6%) were male, and the mean age was 64.9(range, 38-89) years. The technical and clinical success rates were 97.1%(66/68) and 88.2%(60/68), respectively. Overall, 85.3%(58/68) of patients underwent primary tumor resection and primary anastomosis. Surgically successful preoperative colonic stenting was achieved in 77.9%(53/68). The mean duration, defined as the time between the SEMS attempt and surgery, was 11.3 d(range, 0-26 d). The mean hospital stay after surgery was 12.5 d(range, 6-55 d). On multivariate analysis, the use of multiple self-expanding metal stents(OR = 28.872; 95%CI: 1.939-429.956, P = 0.015) was a significant independent risk factor for surgical failure of preoperative stenting as a bridge to surgery. Morbidity and mortality rates in surgery after stent insertion were 4.4%(3/68) and 1.5%(1/68), respectively.CONCLUSION: The use of multiple self-expanding metal stents appears to be a risk factor for surgical failure.

Two-year delay in ulcerative colitis diagnosis is associated with anti-tumor necrosis factor alpha use

BACKGROUND Ulcerative colitis(UC)is an uncommon inflammatory bowel disease(IBD).However,its incidence has recently increased in South Korea.Moreover,UC diagnoses are frequently delayed,and the relationship between diagnostic delay and UC prognosis has not been extensively studied in South Korean patients.AIM To identify meaningful diagnostic delay affecting UC prognosis and to evaluate risk factors associated with diagnostic delay in South Korean patients.METHODS Medical records of 718 patients with UC who visited the outpatient clinic of six university hospitals in South Korea were reviewed;167 cases were excluded because the first symptom date was unknown.We evaluated the relationship between the prognosis and a diagnostic delay of 3,6,12,18,and 24 mo by comparing the prognostic factors[anti-tumor necrosis factor(TNF)-αuse,admission history due to acute flare-ups,frequent admission due to flare-ups,surgery associated with UC,and the clinical remission state at the latest followup]at each diagnostic interval.RESULTS The mean diagnostic interval was 223.3±483.2 d(median,69 d;75th percentile,195 d).Among the prognostic factors,anti-TNFαuse was significantly increased after a diagnostic delay of 24 mo.Clinical risk factors predictive of a 24-mo diagnostic delay were age<60 years at diagnosis[odd ratio(OR)=14.778,95%confidence interval(CI):1.731-126.121],smoking history(OR=2.688,95%CI:1.239-5.747,P=0.012),and misdiagnosis of hemorrhoids(OR=11.066,95%CI:3.596-34.053).Anti-TNFαuse was associated with extensive UC at diagnosis(OR=3.768,95%CI:1.860-7.632)and 24-mo diagnostic delay(OR=2.599,95%CI:1.006-4.916).CONCLUSION A diagnostic delay>24 mo was associated with increased anti-TNFαuse.Age<60 years at diagnosis,smoking history,and misdiagnosis of hemorrhoids were risk factors for delayed diagnosis.

Endoscopic stenting for recurrence-related colorectal anastomotic site obstruction:Preliminary experience

AIM:To evaluate the efficacy of stents in treating patients with anastomotic site obstructions due to cancer recurrence following colorectal surgery.METHODS:The medical records of patients who underwent endoscopic self-expanding metal stents(SEMS)insertion for colorectal obstructions between February2004 and January 2014 were retrospectively reviewed.During the study period,a total of 218 patients underwent endoscopic stenting for colorectal obstructions.We identified and examined the patients who underwent endoscopic stenting for obstructions caused by cancer recurrence at the anastomotic site following colorectal surgeries for primary colorectal cancer.RESULTS:Five consecutive patients[mean age,56.4years(range:39-82 years);4 women,1 man]underwent endoscopic stenting for obstructions caused by cancer recurrence at the anastomotic site following colorectal surgeries for primary colorectal cancer.Technical and clinical success was achieved in all 5 patients,without any early complications.During follow-up,3patients did not need further intervention,prior to their death,after the first stent insertion;thus,the overall success rate was 3/5(60%).Perforations occurred in 2patients who required a second SEMS insertion due to re-obstruction;none of the patients experienced stent migration.CONCLUSION:SEMS placement is a promising treatment option for patients who develop obstructions of their colonic anastomosis sites due to cancer recurrence.

Two-week bismuth-containing quadruple therapy and concomitant therapy are effective first-line treatments for Helicobacter pylori eradication: A prospective open-label randomized trial

BACKGROUND Increasing levels of antibiotic resistance have reduced the Helicobacter pylori(H.pylori)eradication rates afforded by the standard triple therapy.Thus,2-wk firstline four-drug regimens must be considered.AIM To analyze the eradication rates of modified bismuth-containing quadruple therapy(mBCQT)and concomitant therapy(CT),the associated adverse events,and compliance.METHODS Patients infected with H.pylori were prospectively randomized to receive mBCQT or CT for 2 wk.mBCQT featured a proton pump inhibitor(PPI),bismuth,metronidazole,and tetracycline,taken twice daily.CT included a PPI,clarithromycin,metronidazole,and amoxicillin,taken twice daily.The 13C-urea breath test was performed no earlier than 4 wk after therapy concluded to confirm eradication.If either the histological or rapid urease test was positive,H.pylori infection was diagnosed.RESULTS The demographic characteristics of 68 patients who received mBCQT and 68 who received CT did not differ significantly.On intention-to-treat analysis,the eradication rate was 88.2%(60/68)in the mBCQT group and 79.4%(54/68)in the CT group(P=0.162).By per-protocol analysis,the respective eradication rates were 98.4%(60/61)and 93.1%(54/58)(P=0.199).More CT than mBCQT patients experienced adverse events[33.8%(23/68)mBCQT vs 51.5%(35/58)CT patients,respectively,P=0.037].All patients showed good compliance[85.3%(58/68)mBCQT vs 82.4%(56/68)CT patients,P=0.641].CONCLUSION The H.pylori eradication rates of the 2-wk mBCQT and CT regimens are high.Most patients show good compliance,and more CT than mBCQT patients experience adverse events.

Gastric angiodysplasia in a hereditary hemorrhagic telangiectasia type 2 patient

Hereditary hemorrhagic telangiectasia(HHT)is a rare autosomal-dominantly inherited disease that occurs in approximately one in 5000 to 8000 people.Clinical diagnosis of HHT is made when a person presents three of the following four criteria:family history,recurrent nosebleeds,mucocutaneous telangiectasis,and arteriovenous malformations(AVM)in the brain,lung,liver and gastrointestinal(GI)tract.Although epistaxis is themost common presenting symptom,AVMs affecting the lungs,brain and GI tract provoke a more serious outcome.Heterozygous mutations in endoglin,activin receptor-like kinase 1(ACVRL1;ALK1),and SMAD4,the genes involved in the transforming growth factor-βfamily signaling cascade,cause HHT.We report here the case of a 63 year-old male patient who presented melena and GI bleeding episodes,proven to be caused by bleeding from multiple gastric angiodysplasia.Esophagogastroduodenoscopy revealed multiple angiodysplasia throughout the stomach.Endoscopic argon plasma coagulation was performed to control bleeding from a gastric angiodysplasia.The patient has been admitted several times with episodes of hemoptysis and hematochezia.One year ago,the patient was hospitalized due to right-sided weakness,which was caused by left basal ganglia hemorrhage as the part of HHT presentation.In family history,the patient's mother and elder sister had died,due to intracranial hemorrhage,and his eldest son has been suffered from recurrent epistaxis for 20 years.A genetic study revealed a mutation in exon 3 of ALK1(c.199C>T;p.Arg67Trp)in the proband and his eldest son presenting epistaxis.

A case of Cowden syndrome diagnosed from multiple gastric polyposis

Cowden syndrome is a rare autosomal dominant disorder that is characterized by multiple hamartomas in a variety of tissues and this is associated with germline mutations in the phosphatase and tensin homologue (PTEN) gene, which is the tumor suppressor gene located on chromosome 10q23.3. It is characterized by multiple hamartomatous neoplasms of the skin, oral mucosa, gastrointestinal (GI) tract, bones, central nervous system, eyes, and genitourinary tract. Cowden syndrome does not have increased risk of GI malignancy; however, it has an increased risk of breast, thyroid and endometrial cancer development. Herethe authors report a rare case of Cowden syndrome incidentally diagnosed from multiple gastric polyposis. A 29-year-old woman presented with multiple gastric polyps. The laboratory results were normal except for mild anemia, with a hemoglobin level of 11.9 g/dL. Esophagogastroduodenoscopy revealed multiple gastric, duodenal polyps and esophageal acanthosis. Colonoscopy revealed possible hamartomatous polyps in the rectum. Under the suspicion of Cowden syndrome, sonography of the thyroid and breasts was carried out, which revealed multiple thyroid masses. Subsequent fine-needle aspiration biopsy revealed the presence of clusters of follicular epithelial cells, and due to the possibility of malignancy, the patient underwent total thyroidectomy. The pathology was reported as invasive follicular carcinoma. A gene study by direct sequencing showed the presence of a PTEN mutation (c.633C > A /p.Cys211*).

Tailored eradication vs empirical bismuth-containing quadruple therapy for first-line Helicobacter pylori eradication: A comparative,open trial

BACKGROUND Few studies have compared the efficacy and safety profile of a tailored eradication(TR)strategy based on the presence of a 23S ribosomal RNA point mutation with those of empirical bismuth-based quadruple therapy(EBQT)for first-line eradication of Helicobacter pylori(H.pylori)in Korean patients.AIM To compare the efficacy and safety of a TR strategy and those of EBQT regimen as first-line eradication therapy for H.pylori.METHODS This is an open-label,comparative study in which we prospectively enrolled patients over 18 years of age with H.pylori infection and retrospectively reviewed their data.H.pylori-positive patients diagnosed by rapid urease test,Giemsa staining,or dual priming oligonucleotide polymerase chain reaction(DPO-PCR)were enrolled from May 2016 to September 2018 at Gil Medical Center.Patients with H.pylori infection received either a TR regimen or the EBQT regimen.In the tailored therapy group that underwent DPO-PCR testing,patients with A2142G and/or A2143G point mutations were treated with a bismuth-containing quadruple regimen.The eradication rate,patient-reported side effect rate,and H.pylori eradication success rate were evaluated and compared between the groups.RESULTS A total of 150 patients were assigned to the TR(n=50)or EBQT group(n=100).The first-line eradication rate of H.pylori did not differ between the groups(96.0%vs 95.7%,P=0.9).The rate of eradication-related side effects for TR was 12.0%,which differed significantly from that of EBQT(43.0%)for first-line treatment(P<0.001).CONCLUSION DPO-PCR-based TR for H.pylori eradication may be equally efficacious,with less treatment-related complications,compared to EBQT in Korea,where clarithromycin resistance is high.

Tailored eradication strategy vs concomitant therapy for Helicobacter pylori eradication treatment in Korean patients

BACKGROUND Antibiotic resistance to Helicobacter pylori(H.pylori)infection,which ultimately results in eradication failure,has been an emerging issue in the clinical field.Recently,to overcome this problem,an antibiotic sensitivity-based tailored therapy(TT)for H.pylori infection has received attention.AIM To investigate the efficacy and safety profiles of TT for H.pylori infection treatment compared to a non-bismuth quadruple therapy,concomitant therapy(CT)regimen.METHODS We included patients(>18 years)with an H.pylori infection and without a history of Helicobacter eradication who visited the Gil Medical Center between March 2016 and October 2020.After being randomly assigned to either the TT or CT treatment group in 1 to 1 manner,patient compliance,eradication success rate(ESR),and patient-reported side effects profiles were assessed and compared between the two groups.H.pylori infection was diagnosed using a rapid urease test,Giemsa stain,or dual priming oligonucleotide polymerase chain reaction(DPO-PCR).Tailored eradication strategy based through the presence of a 23S ribosomal RNA point mutation.For the TT group,a DPO-PCR test,which detected A2142G and/or A2143G point mutations,and a clarithromycin resistance test were performed.Patients in the clarithromycin-resistant group were treated with a bismuth-containing quadruple combination therapy,while those with sensitive results were treated with the standard triple regimen.RESULTS Of the 217 patients with a treatment naive H.pylori infection,110 patients[mean age:58.66±13.03,men,n=55(50%)]were treated with TT,and 107 patients[mean age:56.67±10.88,men,n=52(48.60%)]were treated with CT.The compliance(TT vs CT,100%vs 98.13%,P=0.30),and follow-up loss rates(8.18%vs 9.35%,P=0.95)were not significantly different between the groups.The ESR after treatment was also not statistically different between the groups(TT vs CT,82.73%vs 82.24%,P=0.95).However,the treatment-related and patient-reported side effects were significantly lower in the TT group than in the CT group(22.77%vs 50.52%,P<0.001).CONCLUSION The DPO-based TT regimen shows promising results in efficacy and safety profiles as a first-line Helicobacter eradication regimen in Korea,especially when physicians are confronted with increased antibiotic resistance rates.

Adult intussusception caused by colonic anisakis: A case report

BACKGROUND Colo-colonic intussusception is an uncommon phenomenon in an adult.Adult intussusception accounts for < 5% of total cases,and the colo-colonic type is < 30% of cases.Although surgical management has been the treatment of choice for intestinal intussusception in adults,because most frequent causes for adult intussusception are malignant in origin,the importance of the roles of preoperative colonoscopic evaluation has recently been emerging.CASE SUMMARY We report an extremely rare case of adult colo-colonic intussusception caused by colonic anisakiasis and successfully treated by endoscopic removal of the Anisakis body.A 59-year-old man visited the emergency department due to 1 day of lower abdominal colicky pain.Abdominopelvic computed tomography (APCT) revealed the presence of mid-transverse colon intussusception without definite necrosis,which was possibly related with colorectal cancer.Because there was no evidence of necrosis at the intussusception site,a colonoscopy was performed to target the colonic lesion and obtain tissue for a histopathological diagnosis.An Anisakis body was found when inspecting the suspicious colonic lesion recorded by APCT.The Anisakis body was removed with forceps assisted by colonoscopy.The patient’s symptoms improved dramatically after removing the Anisakis.A reduced colon without any pathological findings was seen on the follow-up APCT.Without any further treatment,the patient was discharged 5 d after the endoscopy.CONCLUSION When colonic intussusception without necrosis occurs in an adult,physician should consider a colonoscopy to exclude causes cured by endoscopy.

Peroral endoscopic myotomy for treatment of Guillain-Barre syndrome-associated achalasia: A rare case

Guillain-Barre syndrome(GBS)-associated achalasia is a very rare disease of uncertain cause. We report the case of a patient diagnosed with GBS-associated type Ⅰ achalasia who was successfully treated with peroral endoscopic myotomy(POEM). A 30-year-old man who was diagnosed with GBS 3 mo before was referred to our department with dysphagia and mealrelated regurgitation. The results of esophagography, endoscopy, and high-resolution manometry(HRM) revealed type Ⅰ achalasia. POEM that utilized a submucosal tunneling technique was performed to treat the GBS-associated type Ⅰ achalasia. After POEM, smooth passage of a contrast agent into the stomach was shown in follow-up esophagography, and followup HRM revealed a decrease in the mean integrated relaxation pressure 22.9 mm Hg to 9.6 mm Hg. The patient remained without dysphagia for 7 mo, even though the patient's neurological problems were not fully resolved. POEM may be a safe and effective treatment for GBS-associated type Ⅰ achalasia.

A feasible modified biopsy method for tissue diagnosis of gastric subepithelial tumors

AIM: To evaluate the diagnostic yield and safety of a modified technique for the histological diagnosis of subepithelial tumors (SETs). METHODS: A retrospective review of patients who underwent a modified technique for the histological diagnosis of gastric SETs, consisting of a mucosal incision with a fixed flexible snare (MIF) and deep-tissue biopsy under conventional endoscopic view, from January 2012 to January 2013 was performed. Eleven patients with gastric SETs 10-30 mm in diameter and originating from the third or fourth layer on endoscopic ultrasonography were included. RESULTS: The mean age was 59.8 (range, 45-76) years, and 5 patients were male. The mean size of the SETs was 21.8 (range, 11-30) mm. The number of biopsy specimens was 6.3 (range 5-8). The mean procedure time was 9.0 min (range, 4-17 min). The diagnostic yield of MIF biopsies was 90.9% (10/11). The histological diagnoses were leiomyoma (4/11, 36.4%), aberrant pancreas (3/11, 27.3%), gastrointestinal stromal tumors (2/11, 18.2%), an inflammatory fibrinoid tumor (1/11, 9.1%); one result was non-diagnostic (1/11, 9.1%). There were six mesenchymal tumors; the specimens obtained in each case were sufficient for an immunohistochemical diagnosis. There was no major bleeding, but one perforation occurred that was successfully controlled by endoscopic clipping. CONCLUSION: The MIF biopsy was simple to perform, safe, and required a shorter procedure time, with a high diagnostic yield for small SETs.

Clinical outcomes and safety of high-resolution manometry guided superficial partial circular muscle myotomy in per-oral endoscopic myotomy for Jackhammer esophagus: Two cases report

BACKGROUND Jack hammer esophagus is a relatively rare disease and to date,there is no dramatic treatment option.Recently,conventional per-oral endoscopic myotomy (POEM) have expanded their area into Jackhammer esophagus.However,several complications such as post procedure motility disorders (e.g.,passage disturbance) are issues after POEM.To overcome these issues,we here introduced high-resolution manometry (HRM)-guided superficial partial circular muscle myotomy,which involves cutting only the superficial layer of the esophageal circular muscle.CASE SUMMARY We report two cases of patients with Jackhammer esophagus who were treated with HRM-guided extremely superficial partial circular muscle myotomy during POEM.Case 1 was a 53-year-old female with medication-refractory odynophagia and case 2 was a 47-year-old man who presented with chest pain.They were diagnosed with Jackhammer esophagus using HRM,and the hypercontractile segments of the esophagus were identified.HRM-guided extremely superficial partial circular muscle myotomy was performed while preserving the lower esophageal sphincter.Therefore,the circular and longitudinal muscle layers are preserved but hypercontractile movements are reduced,even after POEM.Patients’ clinical symptoms dramatically improved right after POEM,and 6-mo follow-up HRM revealed completely resolved status.During a 1-year follow-up period,patients were still in good health and remained symptom free.CONCLUSION HRM-guided superficial partial circular muscle myotomy may be a promising alternative to conventional POEM for treating Jackhammer esophagus with improved efficacy.