Magnifying endoscopy in upper gastroenterology for assessing lesions before completing endoscopic removal

Any prognosis of gastrointestinal (GI) cancer is closely related to the stage of the disease at diagnosis. Endoscopic submucosal dissection (ESD) and en bloc endoscopic mucosal resection (EMR) have been performed as curative treatments for many early-stage GI lesions in recent years. The technologies have been widely accepted in many Asian countries because they are minimally invasive and supply thorough histopathologic evaluation of the specimens. However, before engaging in endoscopic therapy, an accurate diagnosis is a precondition to effecting the complete cure of the underlying malignancy or carcinoma in situ. For the past few years, many new types of endoscopic techniques, including magnifying endoscopy with narrow-band imaging (ME-NBI), have emerged in many countries because these methods provide a strong indication of early lesions and are very useful in determining treatment options before ESD or EMR. However, to date, there is no comparable classification equivalent to "Kudo's Pit Pattern Classification in the colon", for the upper GI, there is still no clear internationally accepted classification system of magnifying endoscopy. Therefore, in order to help unify some viewpoints, here we will review the defining optical imaging characteristics and the current representative classifications of microvascular and microsurface patterns in the upper GI tract under ME-NBI, describe the accurate relationship between them and the pathological diagnosis, and their clinical applications prior to ESD or en bloc EMR. We will also discuss assessing the differentiation and depth of invasion, defying the lateral spread of involvement and targeting biopsy in real time.     

Diagnosis of gastric intraepithelial neoplasia by narrow-band imaging and confocal laser endomicroscopy

AIM: To evaluate the diagnosis of different differentiated gastric intraepithelial neoplasia (IN) by magnification endoscopy combined with narrow-band imaging (ME-NBI) and confocal laser endomicroscopy (CLE).METHODS: Eligible patients with suspected gastric IN lesions previously diagnosed by endoscopy in secondary hospitals and scheduled for further diagnosis and treatment were recruited for this study. Excluded from the study were patients who had liver cirrhosis, impaired renal function, acute gastrointestinal (GI) bleeding, coagulopathy, esophageal varices, jaundice, and GI post-surgery. Also excluded were those who were pregnant, breastfeeding, were younger than 18 years old, or were unable to provide informed consent. All patients had all mucus and bile cleared from their stomachs. They then received upper GI endoscopy. When a mucosal lesion is found during observation with white-light imaging, the lesion is visualized using maximal magnification, employing gradual movement of the tip of the endoscope to bring the image into focus. Saved images are analyzed. Confocal images were evaluated by two endoscopists (Huang J and Li MY), who were familiar with CLE, blinded to the related information about the lesions, and asked to classify each lesion as either a low grade dysplasia (LGD) or high grade dysplasia (HGD) according to given criteria. The results were compared with the final histopathologic diagnosis. ME-NBI images were evaluated by two endoscopists (Lu ZS and Ling-Hu EQ) who were familiar with NBI, blinded to the related information about the lesions and CLE images, and were asked to classify each lesion as a LGD or HGD according to the “microvascular pattern and surface pattern” classification system. The results were compared with the final histopathologic diagnosis.RESULTS: The study included 32 pathology-proven low grade gastric IN and 26 pathology-proven high grade gastric IN that were detected with any of the modalities. CLE and ME-NBI enabled clear visualization of the vascular microsurface patterns and microvascular structures of the gastric mucosa. The accuracy of the CLE and the ME-NBI diagnosis was 88% (95% CI: 78%-98%) and 81% (95% CI: 69%-93%), respectively. The kappa coefficient of agreement between the histopathology and the in vivo CLE imaging was 0.755; between the histopathology and the in vivo CLE imaging was 0.615. McNemar’s test (binomial distribution used) indicated that the agreement was significant (P < 0.05). When patients were diagnosed by ME-NBI with CLE, the overall accuracy of the diagnosis was 86.21% (95% CI: 73%-96%), and the kappa coefficient of agreement was 0.713, according to McNemar’s test (P < 0.05).CONCLUSION: Higher diagnostic accuracy, sensitivity and specificity of CLE over ME-NBI indicate the feasibility of these two techniques for the efficacious diagnostic classification of gastric IN.     

Endoscopic measurement of variceal diameter

AIM:To measure in vitro diameter of imitational varices using a self-made endoscopic scale and confirm its accuracy and clinical feasibility.METHODS:A catheter was introduced into the endoscopeaccessory channel and attached to a zebra wire guide that was used as a stylet.The wire guide was fixed onto the tip of the catheter by a soft and thin string.By gently advancing the stylet into the catheter,the width of the opening loop at the tip of the endoscope approximated the diameter of the imitational varices.Measurements performed in vitro using this self-made endoscopic ruler were compared to measurements of simulative varices.RESULTS:At the handle,the sleeve moving distance ranged from 5 to 14 mm.There was no obvious proportional relationship between the sleeve movement distance and endoscopic measurement ruler.The results indicated that the gap between the endoscopic measurement and actual measurement of the object size tended to close.The in vitro measurement of the diameter of the simulative varices showed that the two kinds of measuring methods were not significantly different with respect to their accuracy(P=0.8499).CONCLUSION:In vitro experiments confirmed that using a self-designed endoscopic ruler to measure the diameter of simulative varices was objective,accurate and feasible.     

Submucosal tunneling endoscopic resection: An effective and safe therapy for upper gastrointestinal submucosal tumors originating from the muscularis propria layer

AIM To evaluate the effectiveness and safety of submucosal tunneling endoscopic resection(STER) and compare its outcomes in esophageal and cardial submucosal tumors(SMTs) of the muscularis propria(MP) layer.METHODS From May 2012 to November 2017, 173 consecutive patients with upper gastrointestinal(GI) SMTs of the MP layer underwent STER. Overall, 165 patients were included, and 8 were excluded. The baseline characteristics of the patients and SMTs were recorded. The en bloc resection rate, complete resection rate,residual rate, and recurrence rate were calculated to evaluate the effectiveness of STER, and the complication rate was recorded to evaluate its safety. Effectiveness and safety outcomes were compared between esophageal and cardial SMTs.RESULTS One hundred and twelve men and 53 women with a mean age of 46.9 ± 10.8 years were included. The mean tumor size was 22.6 ± 13.6 mm. Eleven SMTs were located in the upper esophagus(6.7%), 49 in the middle esophagus(29.7%), 46 in the lower esophagus(27.9%), and 59 in the cardia(35.7%). Irregular lesions accounted for 48.5% of all lesions. STER achieved an en bloc resection rate of78.7%(128/165) for GI SMTs with an overall complication rate of 21.2%(35/165).All complications resolved without intervention or were treated conservatively without the need for surgery. The en bloc resection rates of esophageal and cardial SMTs were 81.1%(86/106) and 72.1%(42/59), respectively(P = 0.142), and the complication rates were 19.8%(21/106) and 23.7%(14/59), respectively,(P =0.555). The most common complications for esophageal SMTs were gas-related complications and fever, while mucosal injury was the most common for cardial SMTs.CONCLUSION STER is an effective and safe therapy for GI SMTs of the MP layer. Its effectiveness and safety are comparable between SMTs of the esophagus and cardia.     

Optimization therapy for the treatment of chronic hepatitis B

Chronic hepatitis B(CHB)is currently medically managed with either interferon-alpha or one of the five nucleos(t)ide analogs.However,there are still a large number of CHB patients whose response to the above therapies remains less than satisfactory,and their incomplete or non-response to antiviral therapies has plagued clinicians worldwide.In recent years,a newly proposed optimization therapy has provided us with a new approach to solve this problem.The key points in this optimization therapy are to initiate antiviral therapy with an appropriate agent at the correct time point,and to adjust treatments in patients with poor early responses by adding a second agent or switching to another more potent agent.In this review,we summarize recent developments in optimization therapy for the treatment of CHB,and provide an outlook for future research in this field.     

Primary hepatic diffuse large B cell lymphoma: A case report: Primary hepatic diffuse large B cell lymphoma

In this report we describe a rare case of primary hepatic diffuse large B cell lymphoma in a 67-year-old man who presented with abdominal pain, deteriorated liver function, elevated lactate dehydrogenase. He was found to have diffuse nodular intrahepatic space-occupying lesion with normal α-fetoprotein and carcino-embryogenic antigen. The final diagnosis was made by percutaneous biopsy of the liver as the clinical manifestation not consistent with common liver diseases. The patient was treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) without surgical resection with a favorable response. However, serious complication was occurred after 4 cycles of chemotherapy, and the patient finally died of concurrent acute respiratory distress syndrome.     

乙型肝炎病毒准种的临床应用及其研究进展

准种现象普遍存在于RNA病毒中,乙型肝炎病毒(hepatitis B virus,HBV)虽属DNA病毒科,但同样存在准种现象,且其各编码区均可存在准种的特点.HBV在宿主体内是以准种的形式存在和分布的.变异与准种变迁密切相关,变异的多样性是准种产生的根本原因,是准种不断变迁的始动因素,变异的多样性和复杂性预示着准种的多样性和复杂性.HBV准种的变迁影响着患者的临床表现及对抗病毒药物的治疗反应,特别是准种的构成与抗病毒药物的耐药之间存在密切联系.引入准种,有助于我们从整体,动态的角度认识HBV,更加合理有效的预防、诊断和治疗HBV感染.     

Prevalence and risk factors of fatty liver disease in Chengdu,Southwest China

BACKGROUND:Fatty liver disease(FLD)is increasingly recognized as one of the most common chronic liver diseases in China.This study aimed to investigate the prevalence and risk factors of FLD in Chengdu,Southwest China,and to provide a relevant basis for the prevention and intervention of FLD. METHODS:Altogether 9094 subjects(4721 men and 4373 women)of over 18 years old who had received a medical checkup in the West China Hospital of Sichuan University between January and December 2007 were evaluated for FLD...     

Adenoviral transfer of human interleukin-10 gene in lethal pancreatitis

AIM: To evaluate the therapeutic effect of adenoviral-vector-delivered human interleukin-10 (hIL-10) gene on severe acute pancreatitis (SAP) rats. METHODS: Healthy Sprague-Dawley (SD) rats were intraperitoneally injected with adenoviral IL-10 gene (AdvhIL-10), empty vector (Adv0) or PBS solution. Blood, liver, pancreas and lung were harvested on the second day to examine hIL-10 level by ELISA and serum amylase by enzymatic assay. A SAP model was induced by retrograde injection of sodium taurocholate through pancreatic duct. SAP rats were then administered with AdvhIL-10, Adv0and PBS solution by a single intraperitoneal injection 20 min after SAP induction. In addition to serum amylase assay, levels of hIL-10 and tumor necrosis factor-α (TNF-α) were detected by RT-PCR, ELISA and histological study. The mortality rate was studied and analyzed by Kaplan-Meier and log rank analysis.RESULTS: The levels of hIL-10 in the pancreas, liver and lung of healthy rats increased significantly after AdvhIL-10 injection (1.42 ng/g in liver, 0.91 ng/g in pancreas); while there was no significant change of hIL-10 in the other two control groups. The concentration of hIL-10 was increased significantly in the SAP rats after AdvhIL-10 injection (1.68 ng/g in liver, 1.12 ng/g in pancreas) compared to the other two SAP groups with blank vector or PBS treatment (P&lt;0.05). The serum amylase levels remained normal in the AdvhIL-10 transfected healthy rats. However, the serum amylase level was significantly elevated in the other two control SAP rats. In contrast, serum amylase was down-regulated in the AdvhIL-10 treated SAP groups.The TNF-α expression in the AdvhIL-10 treated SAP rats was significantly lower compared to the other two control SAP groups. The pathohistological changes in the AdvhIL-10 treated group were better than those in the other two control groups. Furthermore, the mortality of the AdvhIL-10 treated group was significantly reduced compared to the other two control groups (P&lt;0.05). CONCLUSION: Adenoviral hIL-10 gene can significantly attenuate the severity of SAP rats, and can be used in the treatment of acute inflammation process.