Endoscopic features and treatments of gastric cystica profunda

BACKGROUND Gastric cystica profunda(GCP)represents a rare condition characterized by cystic dilation of gastric glands within the mucosal and/or submucosal layers.GCP is often linked to,or may progress into,early gastric cancer(EGC).AIM To provide a comprehensive evaluation of the endoscopic features of GCP while assessing the efficacy of endoscopic treatment,thereby offering guidance for diagnosis and treatment.METHODS This retrospective study involved 104 patients with GCP who underwent endoscopic resection.Alongside demographic and clinical data,regular patient followups were conducted to assess local recurrence.RESULTS Among the 104 patients diagnosed with GCP who underwent endoscopic resection,12.5%had a history of previous gastric procedures.The primary site predominantly affected was the cardia(38.5%,n=40).GCP commonly exhibited intraluminal growth(99%),regular presentation(74.0%),and ulcerative mucosa(61.5%).The leading endoscopic feature was the mucosal lesion type(59.6%,n=62).The average maximum diameter was 20.9±15.3 mm,with mucosal involvement in 60.6%(n=63).Procedures lasted 73.9±57.5 min,achieving complete resection in 91.3%(n=95).Recurrence(4.8%)was managed via either surgical intervention(n=1)or through endoscopic resection(n=4).Final pathology confirmed that 59.6%of GCP cases were associated with EGC.Univariate analysis indicated that elderly males were more susceptible to GCP associated with EGC.Conversely,multivariate analysis identified lesion morphology and endoscopic features as significant risk factors.Survival analysis demonstrated no statistically significant difference in recurrence between GCP with and without EGC(P=0.72).CONCLUSION The findings suggested that endoscopic resection might serve as an effective and minimally invasive treatment for GCP with or without EGC.

Current progress on the endoscopic features of colorectal sessile serrated lesions

Along with the discovery and refinement of serrated pathways,the World Health Organization amended the classification of digestive system tumors in 2019,recommending the renaming of sessile serrated adenomas/polyps to sessile serrated lesions(SSLs).Given the particularity of the endoscopic appearance of SSLs,it could easily be overlooked and missed in colonoscopy screening,which is crucial for the occurrence of interval colorectal cancer.Existing literature has found that adequate bowel preparation,reasonable withdrawal time,and awareness of colorectal SSLs have improved the quality and accuracy of detection.More particularly,with the continuous advancement and development of endoscopy technology,equipment,and accessories,a potent auxiliary tool is provided for accurate observation and immediate diagnosis of SSLs.Highdefinition white light endoscopy,chromoendoscopy,and magnifying endoscopy have distinct roles in the detection of colorectal SSLs and are valuable in identifying the size,shape,character,risk degree,and potential malignant tendency.This article delves into the relevant factors influencing the detection rate of colorectal SSLs,reviews its characteristics under various endoscopic techniques,and expects to attract the attention of colonoscopists.

Usefulness of analyzing endoscopic features in identifying the colorectal serrated sessile lesions with and without dysplasia

BACKGROUND Sessile serrated lesions(SSLs)are often missed on colonoscopy,and studies have shown this to be an essential cause of interstitial colorectal cancer.The SSLs with dysplasia(SSL-D+),in particular,have a faster rate of carcinogenesis than conventional tubular adenomas.Therefore,there is a clinical need for some endoscopic features with independent diagnostic value for SSL-D+s to assist endoscopists in making immediate diagnoses,thus improving the quality of endoscopic examination and treatment.AIM To compare the characteristics of SSLs,including those with and without dysplasia(SSL-D+and SSL-D-),based on white light and image-enhanced endoscopy,to achieve an immediate differential diagnosis for endoscopists.METHODS From January 2017 to February 2023,cases of colorectal SSLs confirmed by colonoscopy and histopathology at the Gastrointestinal Endoscopy Center of Beijing Tsinghua Changgung Hospital were collected.The general,endoscopic,and histopathological data were reviewed and analyzed to determine the diagnostic utility.Univariate analysis was used to find potential diagnostic factors,and then multivariate regression analysis was performed to derive endoscopic features with independent diagnostic values for the SSL-D+.RESULTS A total of 228 patients with 253 lesions were collected as a result.There were 225 cases of colorectal SSL-D-s and 28 cases of SSL-D+s.Compared to the colorectal SSL-D-,the SSL-D+was more common in the right colon(P=0.027)with complex patterns of depression,nodule,and elevation based on cloud-like surfaces(P=0.003),reddish(P<0.001),microvascular varicose(P<0.001),and mixed type(Pit II,II-O,IIIL,IV)of crypt opening based on Pit II-O(P<0.001).Multifactorial logistic regression analysis indicated that lesions had a reddish color[odds ratio(OR)=18.705,95%confidence interval(CI):3.684-94.974],microvascular varicose(OR=6.768,95%CI:1.717-26.677),and mixed pattern of crypt opening(OR=20.704,95%CI:2.955-145.086)as the independent predictors for SSL-D+s.CONCLUSION The endoscopic feature that has independent diagnostic value for SSL-D+is a reddish color,microvascular varicose,and mixed pattern of crypt openings.

Endoscopic and pathological characteristics of de novo colorectal cancer:Retrospective cohort study

BACKGROUND Endoscopy has rapidly developed in recent years and has enabled further investigation into the origin and features of intestinal tumors.The small size and concealed position of these tumors make it difficult to distinguish them from nonneoplastic polyps and carcinoma in adenoma(CIA).The invasive depth and metastatic potential determine the operation regimen,which in turn affects the overall survival and distant prognosis.The previous studies have confirmed the malignant features and clinicopathological features of de novo colorectal cancer(CRC).AIM To provide assistance for diagnosis and treatment,but the lack of a summary of endoscopic features and assessment of risk factors that differ from the CIA prompted us to conduct this retrospective study.METHODS In total,167 patients with small-sized CRCs diagnosed by endoscopy were reviewed.The patients diagnosed as advanced CRCs and other malignant cancers or chronic diseases that could affect distant outcomes were excluded.After screening,63 cases were excluded,including 33 de novo and 30 CIA cases.Patient information,including their follow-up information,was obtained from an electronic His-system.The characteristics between two group and risk factors for invasion depth were analyzed with SPSS 25.0 software.RESULTS Nearly half of the de novo CRCs were smaller than 1 cm(n=16,48.5%)and the majority were located in the distal colon(n=26,78.8%).The IIc type was the most common macroscopic type of de novo CRC.In a Pearson analysis,the differential degree,Sano,JNET,and Kudo types,surrounding mucosa,and chicken skin mucosa(CSM)were correlated with the invasion depth(P<0.001).CSM was a significant risk factor for deep invasion and disturbed judgment of endoscopic ultrasound.A high degree of tumor budding and tumor-infiltrating lymphocytes are accompanied by malignancy.Finally,de novo CRCs have worse outcomes than CIA CRCs.CONCLUSION This is the first comprehensive study to analyze the features of de novo CRCs to distinguish them from nonneoplastic polyps.It is also the first study paying attention to CSM invasive depth measurement.This study emphasizes the high metastatic potential of de novo CRCs and highlights the need for more research on this tumor type.

Chicken skin mucosa surrounding small colorectal cancer could be an endoscopic predictive marker of submucosal invasion

BACKGROUND Chicken skin mucosa(CSM)surrounding colon polyps is a common endoscopic finding with pale yellow-speckled mucosa during a colonoscopy screening.Although reports about CSM surrounding small colorectal cancer are scarce,and its clinical significance in intramucosal and submucosal cancers is unclear,previous studies have suggested it could be an endoscopic predictive marker for colonic neoplastic and advanced polyps.Currently,because of the inaccurate preoperative evaluation by endoscopists,many small colorectal cancers,particularly lesions with a diameter<2 cm,are improperly treated.Therefore,more effective methods are required to better assess the depth of the lesion before treatment.AIM To explore potential markers of small colorectal cancer early invasion under white light endoscopy,providing patients with better treatment alternatives.METHODS This retrospective cross-sectional study included 198 consecutive patients[233 early colorectal cancers(ECCs)]who underwent endoscopy or surgical procedures at the Digestive Endoscopy Center of Chengdu Second People’s Hospital between January 2021 and August 2022.The participants had pathologically confirmed colorectal cancer with a lesion diameter<2 cm and received endoscopic or surgical treatment,including endoscopic mucosal resection and submucosal dissection.Clinical pathology and endoscopy parameters,including tumor size,invasion depth,anatomical position,and morphology,were reviewed.Fisher’s exact test,theχ2 test,and Student’s t-test were used to analyze the patient’s basic characteristics.Logistic regression analysis was used to examine the relationship between morphological characteristics,size,CSM prevalence,and ECC invasion depth under white light endoscopy.Statistical significance was set at P<0.05.RESULTS The submucosal carcinoma(SM stage)was larger than the mucosal carcinoma(M stage)with a significant difference(17.2±4.1 vs 13.4±4.6 mm,P<0.01).M-and SM-stage cancers were common in the left colon;however,no significant differences were found between them(151/196,77%and 32/37,86.5%,respectively,P=0.199).The endoscopic features of colorectal cancer revealed that CSM,depressed areas with clear boundaries,and erosion or ulcer bleeding were more common in the SM-stage cancer group than in the M-stage cancer group(59.5%vs 26.2%,46%vs 8.7%,and 27.3%vs 4.1%,respectively,P<0.05).CSM prevalence in this study was 31.3%(73/233).The positive rates of CSM in flat,protruded,and sessile lesions were 18%(11/61),30.6%(30/98),and 43.2%(32/74),respectively,with significant differences(P=0.007).CONCLUSION CSM-related small colorectal cancer was primarily located in the left colon and could be a predictive marker of submucosal invasion in the left colon.

Endoscopic classification and pathological features of primary intestinal lymphangiectasia

BACKGROUND The appearance of the intestinal mucosa during endoscopy varies among patients with primary intestinal lymphangiectasia(PIL).AIM To classify the endoscopic features of the intestinal mucosa in PIL under endoscopy,combine the patients’imaging and pathological characteristics of the patients,and explain their causes.METHODS We retrospectively analyzed the endoscopic images of 123 patients with PIL who were treated at the hospital between January 1,2007 and December 31,2018.We compared and analyzed all endoscopic images,classified them into four types according to the endoscopic features of the intestinal mucosa,and analyzed the post-lymphographic computed tomography(PLCT)and pathological characteristics of each type.RESULTS According to the endoscopic features of PIL in 123 patients observed during endoscopy,they were classified into four types:nodular-type,granular-type,vesicular-type,and edematous-type.PLCT showed diffuse thickening of the small intestinal wall,and no contrast agent was seen in the small intestinal wall and mesentery in the patients with nodular and granular types.Contrast agent was scattered in the small intestinal wall and mesentery in the patients with vesicular and edematous types.Analysis of the small intestinal mucosal pathology revealed that nodular-type and granulartype lymphangiectasia involved the small intestine mucosa in four layers,whereas ectasia of the vesicular-and edematous-type lymphatic vessels largely involved the lamina propria mucosae,submucosae,and muscular layers.CONCLUSION Endoscopic classification,combined with the patients’clinical manifestations and pathological examination results,is significant and very useful to clinicians when scoping patients with suspected PIL.

Role of endoscopic ultrasound in the characterization of solid pseudopapillary neoplasm of the pancreas

BACKGROUND Solid pseudopapillary neoplasm(SPN)is an uncommon pathology of the pancreas with unpredictable malignant potential.Endoscopic ultrasound(EUS)assessment plays a vital role in lesion characterization and confirmation of the tissue diagnosis.However,there is a paucity of data regarding the imaging assessment of these lesions.AIM To determine the characteristic EUS features of SPN and define its role in preoperative assessment.METHODS This was an international,multicenter,retrospective,observational study of prospective cohorts from 7 large hepatopancreaticobiliary centers.All cases with postoperative histology of SPN were included in the study.Data collected included clinical,biochemical,histological and EUS characteristics.RESULTS One hundred and six patients with the diagnosis of SPN were included.The mean age was 26 years(range 9 to 70 years),with female predominance(89.6%).The most frequent clinical presentation was abdominal pain(80/106;75.5%).The mean diameter of the lesion was 53.7 mm(range 15 to 130 mm),with the slight predominant location in the head of the pancreas(44/106;41.5%).The majority of lesions presented with solid imaging features(59/106;55.7%)although 33.0%(35/106)had mixed solid/cystic characteristics and 11.3%(12/106)had cystic morphology.Calcification was observed in only 4(3.8%)cases.Main pancreatic duct dilation was uncommon,evident in only 2 cases(1.9%),whilst common bile duct dilation was observed in 5(11.3%)cases.One patient demonstrated a double duct sign at presentation.Elastography and Doppler evaluation demonstrated inconsistent appearances with no emergence of a predictable pattern.EUS guided biopsy was performed using three different types of needles:Fine needle aspiration(67/106;63.2%),fine needle biopsy(37/106;34.9%),and Sonar Trucut(2/106;1.9%).The diagnosis was conclusive in 103(97.2%)cases.Ninety-seven patients were treated surgically(91.5%)and the post-surgical SPN diagnosis was confirmed in all cases.During the 2-year follow-up period,no recurrence was observed.CONCLUSION SPN presented primarily as a solid lesion on endosonographic assessment.The lesion tended to be located in the head or body of the pancreas.There was no consistent characteristic pattern apparent on either elastography or Doppler assessment.Similarly SPN did not frequently cause stricture of the pancreatic duct or common bile duct.Importantly,we confirmed that EUS-guided biopsy was an efficient and safe diagnostic tool.The needle type used does not appear to have a significant impact on the diagnostic yield.Overall SPN remains a challenging diagnosis based on EUS imaging with no pathognomonic features.EUS guided biopsy remains the gold standard in establishing the diagnosis.

Endoscopic diagnosis for colorectal sessile serrated lesions

BACKGROUND Hyperplastic polyps are considered non-neoplastic, whereas sessile serrated lesions(SSLs) are precursors of cancer via the ‘‘serrated neoplastic pathway’’. The clinical features of SSLs are tumor size(> 5 mm), location in the proximal colon, coverage with abundant mucus called the ‘‘mucus cap’’, indistinct borders, and a cloud-like surface. The features in magnifying narrow-band imaging are varicose microvascular vessels and expanded crypt openings. However, accurate diagnosis is often difficult.AIM To develop a diagnostic score system for SSLs.METHODS We retrospectively reviewed consecutive patients who underwent endoscopic resection during colonoscopy at the Toyoshima endoscopy clinic. We collected data on serrated polyps diagnosed by endoscopic or pathological examination. The significant factors for the diagnosis of SSLs were assessed using logistic regression analysis. Each item that was significant in multivariate analysis was assigned 1 point, with the sum of these points defined as the endoscopic SSL diagnosis score. The optimal cut-off value of the endoscopic SSL diagnosis score was determined by receiver-operating characteristic curve analysis.RESULTS Among 1288 polyps that were endoscopically removed, we analyzed 232 diagnosed as serrated polyps by endoscopic or pathological examination. In the univariate analysis, the location(proximal colon), size(> 5 mm), mucus cap, indistinct borders, cloud-like surface, and varicose microvascular vessels were significantly associated with the diagnosis of SSLs. In the multivariate analysis, size(> 5 mm;P = 0.033), mucus cap(P = 0.005), and indistinct borders(P = 0.033) were independently associated with the diagnosis of SSLs. Size > 5 mm, mucus cap, and indistinct borders were assigned 1 point each and the sum of these points was defined as the endoscopic SSL diagnosis score. The receiver-operating characteristic curve analysis showed an optimal cut-off score of 3, which predicted pathological SSLs with 75% sensitivity, 80% specificity, and 78.4% accuracy. The pathological SSL rate for an endoscopic SSL diagnosis score of 3 was significantly higher than that for an endoscopic SSL diagnosis score of 0, 1, or 2(P < 0.001).CONCLUSION Size > 5 mm, mucus cap, and indistinct borders were significant endoscopic features for the diagnosis of SSLs. Serrated polyps with these three features should be removed during colonoscopy.

Construction and analysis of an ulcer risk prediction model after endoscopic submucosal dissection for early gastric cancer

BACKGROUND Endoscopic submucosal dissection(ESD) has been widely used in the treatment of early gastric cancer(EGC). A personalized and effective prediction method for ESD with EGC is urgently needed.AIM To construct a risk prediction model for ulcers after ESD for EGC based on LASSO regression.METHODS A total of 196 patients with EGC who received ESD treatment were prospectively selected as the research subjects and followed up for one month. They were divided into an ulcer group and a non-ulcer group according to whether ulcers occurred. The general data, pathology, and endoscopic characteristics of the groups were compared, and the best risk predictor subsets were screened by LASSO regression and tenfold cross-validation. Multivariate logistic regression was applied to analyze the risk factors for ulcers after ESD in patients with EGC. A receiver operating characteristic(ROC) curve was used to estimate the predictive model performance.RESULTS One month after the operation, no patient was lost to follow-up. The incidence of ulcers was 20.41%(40/196)(ulcer group), and the incidence of no ulcers was 79.59%(156/196)(non-ulcer group). There were statistically significant differences in the course of disease, Helicobacter pylori infection history, smoking history, tumor number, clopidogrel medication history, lesion diameter, infiltration depth, convergent folds, and mucosal discoloration between the groups. Gray’s medication history, lesion diameter, convergent folds, and mucosal discoloration, which were the 4 nonzero regression coefficients, were screened by LASSO regression analysis. Further multivariate logistic analysis showed that lesion diameter [Odds ratios(OR) = 30.490, 95%CI: 8.584-108.294], convergent folds(OR = 3.860, 95%CI: 1.060-14.055), mucosal discoloration(OR = 3.191, 95%CI: 1.016-10.021), and history of clopidogrel(OR = 3.554, 95%CI: 1.009-12.515) were independent risk factors for ulcers after ESD in patients with EGC(P < 0.05). The ROC curve showed that the area under the curve of the risk prediction model for ulcers after ESD in patients with EGC was 0.944(95%CI: 0.902-0.972).CONCLUSION Clopidogrel medication history, lesion diameter, convergent folds, and mucosal discoloration can predict the occurrence of ulcers after ESD in patients with EGC.