胆囊息肉是临床上比较常见的良性胆道系统疾病，目前对此类疾病的治疗以胆囊切除术为主。鉴于胆囊切除后的不良反应和并发症，及患者保胆期望愈发强烈，经皮经肝胆道镜、胆道镜保胆取息肉术、经自然腔道内镜保胆息肉切除术等保胆微创方法相继提出。本文旨在对目前文献报道的胆囊息肉保胆微创治疗的手术方式、临床疗效等进行整理归纳，为临床上非肿瘤性胆囊息肉的治疗提供保胆新思路。

BackgroundEndoscopic full-thickness resection (EFTR) is a standard treatment method for gastric gastrointestinal stromal tumors (gGISTs). Evidence of the safety and efficacy of a double-curved endoscope (DCE) in EFTR of gGISTs is limited. We aimed to compare the operative outcomes of DCE versus single-curved endoscopes (SCE) in EFTR of gGISTs.Material and methodsThis retrospective observational study was conducted at four Chinese tertiary institutes. From January 2019 to November 2021, 104 patients who underwent EFTR by SCE (n = 57) or DCE (n = 47) were enrolled. One-to-one propensity score matching (PSM) was performed between the two groups to compare the demographics and operative outcomes.ResultsAll gGISTs were resected successfully with no recurrence during follow-up. The median (range) tumor size was 1.2 (0.5, 3.5) cm in DCE and 2.0 (0.6, 4.8) cm in SCE (p < .001), and the procedure time was shorter in the DCE group than in the SCE group (50.0 min vs. 62.0 min, p < .05). After PSM, 41 pairs were selected, and no difference was noted in demographics. The procedure time was also shorter in the DCE group than in the SCE group (50.0 min vs. 55.0 min, p < .05). Subgroup analysis showed that the DCE group had a shorter procedure time in the gastric fundus than the SCE group (47.0 min vs. 55.0 min, p < .05). In multiple linear regression analysis, significant factors related to prolonged procedure time were the type of endoscope of SCE and larger tumor size (p < .05).ConclusionsEFTR of gGISTs using DCE is safe and effective. Compared with SCE, DCE had an advantage in terms of operative time, especially in the gastric fundus.

BackgroundEndoscopic resection (ER) is a proven treatment for gastric gastrointestinal stromal tumors (gGISTs). We aimed to assess the learning curve (LC) associated with ER for gGISTs and identify determinants.MethodsWe conducted an analysis of 289 patients who underwent the ER of gGISTs by an experienced endoscopist. To characterize the LC, we employed cumulative sum analysis of the duration of surgery. The participants were divided into an early phase (cases 1-50) and a later phase (case 51-289), which were compared. Furthermore, we identified risk factors for the conversion from endoscopic to laparoscopic resection (LR).ResultsThe durations of surgery and hospitalization were shorter, and there were fewer complications and fasting days in the later phase. The conversion rates to LR were 6.0% and 2.5% in the early and later phases, respectively. The tumor diameter (& GE;3.0 cm) and invasion beyond the muscularis propria were significant risk factors for conversion to LR (odds ratio 17.92, 95% confidence interval 2.66-120.87; and 58.03, 6.40-525.84; respectively).ConclusionsThe LC for ER of gGISTs lasts for approximately 50 cases. In addition, tumors & GE;3.0 cm in diameter and those that invade beyond the muscularis propria are more likely to require conversion to LR.

Objective Endoscopic resection (ER) of gastric gastrointestinal stromal tumors (gGISTs) is a commonly used treatment; however, it is associated with a risk of conversion to laparoscopic resection (LR). This study was performed to identify factors influencing conversion from ER to LR and the effects of conversion on outcomes. Methods The clinicopathological features of patients treated for gGISTs from March 2010 to May 2021 were retrospectively collected. Endpoints included the determination of risk factors associated with LR conversion, with comparisons of surgical outcomes with and without conversion. Propensity score matching was performed to compare the two groups. Results In total, 371 gGISTs were analyzed. Sixteen patients required conversion from ER to LR. Propensity score matching demonstrated that invasion depth (muscularis propria with exophytic growth) and gGIST size (≥3 cm) were independent risk factors for conversion to LR. The procedure duration (median, 160.5 vs. 60.0 minutes), postoperative hospitalization duration (median, 8 vs. 6 days), and postoperative fasting duration (median, 5 vs. 3 days) were significantly longer in patients who underwent conversion to LR. Conclusions Accurate preoperative measurements of tumor size and invasion depth may help determine more appropriate surgical approaches for patients with gGISTs.

Endoscopic resection (ER) is widely used in treating gastric gastrointestinal stromal tumors (gGISTs); however, complications occur frequently after resection. We aimed to determine factors associated with postoperative complications for ER of gGISTs. This was a retrospective, multi-center, observational study. Consecutive patients who underwent ER of gGISTs at five institutes from January 2013 to December 2022 were analyzed. The risk factors for delayed bleeding and postoperative infection were assessed. A total of 513 cases were finally analyzed. Of 513 patients, 27 (5.3

BACKGROUNDCurrent endoscopic methods in the control of acute nonvariceal bleeding have a small but clinically significant failure rate. The role of over-the-scope clips (OTSCs) as the first treatment has not been defined.OBJECTIVETo compare OTSCs with standard endoscopic hemostatic treatments in the control of bleeding from nonvariceal upper gastrointestinal causes.DESIGNA multicenter, randomized controlled trial. (ClinicalTrials.gov: NCT03216395).SETTINGUniversity teaching hospitals in Hong Kong, China, and Australia.PATIENTS190 adult patients with active bleeding or a nonbleeding visible vessel from a nonvariceal cause on upper gastrointestinal endoscopy.INTERVENTIONStandard hemostatic treatment (n = 97) or OTSC (n = 93).MEASUREMENTSThe primary outcome was 30-day probability of further bleeds. Other outcomes included failure to control bleeding after assigned endoscopic treatment, recurrent bleeding after initial hemostasis, further intervention, blood transfusion, and hospitalization.RESULTSThe 30-day probability of further bleeding in the standard treatment and OTSC groups was 14.6% (14 of 97) and 3.2% (3 of 93), respectively (risk difference, 11.4 percentage points [95% CI, 3.3 to 20.0 percentage points]; P = 0.006). Failure to control bleeding after assigned endoscopic treatment in the standard treatment and OTSC groups was 6 versus 1 (risk difference, 5.1 percentage points [CI, 0.7 to 11.8 percentage points]), respectively, and 30-day recurrent bleeding was 8 versus 2 (risk difference, 6.6 percentage points [CI, -0.3 to 14.4 percentage points]), respectively. The need for further interventions was 8 versus 2, respectively. Thirty-day mortality was 4 versus 2, respectively. In a post hoc analysis with a composite end point of failure to successfully apply assigned treatment and further bleeds, the event rate was 15 of 97 (15.6%) and 6 of 93 (6.5%) in the standard and OTSC groups, respectively (risk difference, 9.1 percentage points [CI, 0.004 to 18.3 percentage points]).LIMITATIONClinicians were not blinded to treatment and the option of crossover treatment.CONCLUSIONOver-the-scope clips, as an initial treatment, may be better than standard treatment in reducing the risk for further bleeding from nonvariceal upper gastrointestinal causes that are amenable to OTSC placement.PRIMARY FUNDING SOURCEGeneral Research Fund to the University Grant Committee, Hong Kong SAR Government.

BackgroundAccurate preoperative assessment of surgical difficulty is crucial to the success of the surgery and patient safety. This study aimed to evaluate the difficulty for endoscopic resection (ER) of gastric gastrointestinal stromal tumors (gGISTs) using multiple machine learning (ML) algorithms.MethodsFrom December 2010 to December 2022, 555 patients with gGISTs in multi-centers were retrospectively studied and assigned to a training, validation, and test cohort. A difficult case was defined as meeting one of the following criteria: an operative time ≥ 90 min, severe intraoperative bleeding, or conversion to laparoscopic resection. Five types of algorithms were employed in building models, including traditional logistic regression (LR) and automated machine learning (AutoML) analysis (gradient boost machine (GBM), deep neural net (DL), generalized linear model (GLM), and default random forest (DRF)). We assessed the performance of the models using the areas under the receiver operating characteristic curves (AUC), the calibration curve, and the decision curve analysis (DCA) based on LR, as well as feature importance, SHapley Additive exPlanation (SHAP) Plots and Local Interpretable Model Agnostic Explanation (LIME) based on AutoML.ResultsThe GBM model outperformed other models with an AUC of 0.894 in the validation and 0.791 in the test cohorts. Furthermore, the GBM model achieved the highest accuracy among these AutoML models, with 0.935 and 0.911 in the validation and test cohorts, respectively. In addition, it was found that tumor size and endoscopists’ experience were the most prominent features that significantly impacted the AutoML model’s performance in predicting the difficulty for ER of gGISTs.ConclusionThe AutoML model based on the GBM algorithm can accurately predict the difficulty for ER of gGISTs before surgery.

经口内镜下肌切开术（peroral endoscopic myotomy，POEM）是一种通过切开食管下括约肌，改善贲门失弛缓症临床症状的微创内镜技术。作为近年来的新兴内镜技术，POEM症状缓解率高、并发症发生率低，且具有恢复快、费用低等优势。随着研究者们对POEM的关注度越来越高，有关POEM的手术方式有了新的研究进展，本文就POEM标准术式的改进、改良术式及衍生术式作一概述。

Background Endoscopic resection (ER) is a promising technique for resecting gastric gastrointestinal stromal tumors (gGISTs); however, ER is technically challenging. This study aimed to develop and validate a difficulty scoring system (DSS) to determine the difficulty for ER of a gGIST. Methods This retrospective study enrolled 555 patients with gGISTs in multi-centers from December 2010 to December 2022. Data on patients, lesions, and outcomes of ER were collected and analyzed. A difficult case was defined as an operative time ≥ 90 min, or the occurrence of severe intraoperative bleeding, or conversion to laparoscopic resection. The DSS was developed in the training cohort (TC) and validated in the internal validation cohort (IVC) and external validation cohort (EVC). Results The difficulty occurred in 97 cases (17.5%). The DSS comprised the following: tumor size ≥ 3.0 cm (3 points) or 2.0–3.0 cm (1 point); location in the upper third of the stomach (2 points); invasion depth beyond the muscularis propria (2 points); lack of experience (1 point). The area under the curve (AUC) of DSS in IVC and EVC was 0.838 and 0.864, respectively, and the negative predictive value (NPV) was 0.923 and 0.972, respectively. The proportions of difficult operation in easy (score 0–3), intermediate (score 4–5), and difficult (score 6–8) categories were 6.5%, 29.4%, and 88.2% in the TC, 7.7%, 45.8%, and 85.7% in the IVC, and 7.0%, 29.4%, and 85.7% in the EVC, respectively. Conclusions We developed and validated a preoperative DSS for ER of gGISTs based on tumor size, location, invasion depth, and endoscopists’ experience. This DSS can be used to grade the technical difficulty before surgery.

BACKGROUND:endoscopic resection (ER) is widely used in the treatment of gastric gastrointestinal stromal tumors (gGISTs). However, no studies have previously described the learning curve (LC) for ER of gGISTs. This study aimed to evaluate the LC based on multifarious operative outcomes.METHODS:one hundred consecutive patients who underwent ER of gGISTs by a single endoscopist from January 2017 to December 2022 were included. Patients were analyzed in groups of ten to minimize demographic differences, and operative time (OT), conversion rate, intraoperative and postoperative complication were assessed to evaluate the LC. Meanwhile, for the OT, the LC was further analyzed using the cumulative sum (CUSUM) method and patients were organized chronologically in three phases.RESULT:there was a statistically significant decrease in OT, conversion to laparoscopic surgery, and postoperative complication after 30 cases (median 80.0 min vs 56.0 min, p < 0.001; 10.0 % vs 0 %, p = 0.025; 33.3 % vs 10.0 %, p = 0.004), rate of intraoperative complications after 20 cases (15.0 % vs 1.3 %, p = 0.025). CUSUM chart demonstrated that OT increased dramatically before around 30 cases (phase 1) and decreased after 60 cases (phase 3), with a plateau phase in the middle 30 cases (phase 2). Among the three phases, the R0 resection and conversion rate were not significantly different. However, OT, intraoperative and postoperative complications were gradually decreased (p < 0.05).CONCLUSIONS:the LC of ER of gGISTs is approximately 60 cases. However, about 30 cases were sufficient to acquire skills to reduce complications and conversion rate during the ER procedure.

Objective:To study the efficacy and safety of EndoClot polysaccharide hemostatic system (EndoClot PHS) for heparinized arterial hemorrhage of upper digestive tract (Forrest Ⅰa) in animal model.Methods:Twelve experimental pigs were randomly divided into the test group ( n=6) and the control group ( n=6) by simple random grouping method. Gastric arterial hemorrhage models were established. Endoclot PHS and Hemospray were used to spray on the wound to stop bleeding in the test group and the control group respectively. The time of effective hemostasis, the amount of hemostatic particles used, and the blockage of the powder feeding tube and its replacement were compared between the two groups. The survival and complications of experimental pigs were observed after the operation. In 10 days after the operation, the experimental pigs were euthanized for pathological dissection. Results:Spurting or pulsatile bleeding was achieved in all experimental pigs. There were significant differences in the time of effective hemostasis (8.75±0.84 min VS 9.83±0.62 min, t=-2.53, P=0.030) and the amount of hemostatic particles used to achieve effective hemostasis (6.71±0.39 g VS 14.10±1.62 g, t=-10.86, P<0.001) between the test group and the control group. There was no significant difference in the occurence of clogging or the replacement of powder feeding pipes between the two groups (0.64±0.02 times VS 0.67±0.04 times, t=-1.64, P=0.131). In addition, the gas source of the test group was stable, and the visual field under the endoscope was clear. Neither the test group nor the control group had gastric lesions, perforation, or embolism. The blood glucose, blood routine, and liver and kidney functions were normal, and no thrombosis or embolism of the main organs occurred in either group. Conclusion:EndoClot PHS is safe and effective for heparinized upper gastrointestinal arterial hemorrhage (Forrest Ⅰa) in animal models.

To evaluate the psychological symptoms of patients with Crohn disease (CD), and to explore the risk factors affecting quality of life (QOL) in CD patients, 50 adult patients with CD, and 50 healthy controls were enrolled. Psychological questionnaires including self-rating anxiety scale (SAS), self-rating depression scale (SDS), the inflammatory bowel disease questionnaire (IBDQ) and the short form-36 health survey (SF-36) were completed. The results showed both the SAS (40.3±8.5 VS 37.6±7.0) and the SDS (47.1±11.1 VS 41.8±9.6) in CD patients were significantly higher than those in the healthy controls ( t=5.4, P<0.05; t=10.6, P<0.05). The IBDQ scores revealed the physical symptoms scores were 49.50±7.62, systemic symptoms scores 23.92±5.07, emotional functions scores 57.13±15.62, and social function scores 22.15±9.08 in CD active phase. However, the above scores were 60.12±4.01, 26.24±3.97, 67.34±15.17, and 25.44±2.03 respectively in the remission phase. Four subscale items of IBDQ in CD active phase were significant lower than those in the remission phase (all P<0.05). The subscale items of SF-36 scores (PF, RP, BP, GH, VT, SF, RE, MH) in CD patients were significant lower than those in healthy controls (all P<0.05). The SF-36 items scores of PF,RP and MH in the remission phase were significant higher than those in the active phase (all P<0.05). The SF-36 items scores of GH and VT in patients with malnutrition were significant lower than those with nutrition (both P<0.05). Multivariate regression analysis showed that disease status and nutritional risk ( P<0.05) significantly affected the patients' IBDQ scores. Factors including sex, age, marital status, education background, medical insurance, use of biologicals, surgery treatment had little influence on the total score of IBDQ ( P>0.05). Psychological conseling and treatment in the active phase may improve QOL of CD patients.

Background Patients with early gastric cancer undergoing noncurative endoscopic submucosal dissection (ESD) have a risk of tumor recurrence and metastasis, and some patients need additional surgery. The purpose of this study was to explore the risk factors of cancer residue and lymph node (LN) metastasis after noncurative ESD for early gastric cancer and to compare the short outcome of early and delayed additional surgery. Methods The clinicopathological characteristics of 30 early gastric cancer patients who received noncurative ESD and additional surgery were studied retrospectively. Multivariable regression was utilized to examine the independent risk factors for residual cancer and LN metastasis. Receiver operating characteristic curve was used to analyze the multivariable model's predictive performance. Furthermore, the perioperative safety and radical tumor performance of early surgery (≤30 days, n = 11), delayed surgery (>30 days, n = 11) after ESD, and upfront surgery (n = 59) were compared. Results Multivariable regression showed that diffuse type of Lauren classification, submucosal invasion, and positive human epidermal growth factor receptor-2 (HER-2) were risk factors for residual cancer. Undifferentiated carcinoma, vascular invasion, and positive vertical margin were risk factors for LN metastasis. The area under the curve (AUC) of the multifactor model predicting cancer residue and LN metastasis was 0.761 and 0.792, respectively. The early surgery group experienced higher intraoperative blood loss and a longer operation time than the delayed surgery and upfront surgery groups. There was no significant difference in the number of LN dissections, LN metastasis rate, and postoperative complications among the three groups. Conclusion Diffuse type of Lauren classification, submucosal invasion, and positive HER-2 are risk factors for residual cancer, while undifferentiated carcinoma, vascular invasion, and positive vertical margin are risk factors for LN metastasis. Delayed additional surgery after ESD (>30 days) has higher intraoperative safety, without affecting the radical resection in early gastric cancer patients.

目的 综合评估消化内镜下止血技术在急性非静脉曲张性上消化道出血(acute non-variceal upper gastrointestinal bleeding,ANVUGIB)中的临床疗效及经济效益.方法 采用回顾性研究方法,选取2018年10月—2020年10月在苏州大学附属第一医院总院区就诊的95例ANVUGIB患者,按照是否予以内镜下止血治疗,将其分为观察组(n=59)及对照组(n=36).观察组采用消化内镜下止血,对照组采用抑酸、止血等药物保守疗法进行治疗.通过比较两组的止血有效率、再出血率、输血率、住院时间、住院总费用来综合比较两种方法对治疗ANVUGIB的临床价值.在观察组中进行亚组分析,比较常规内镜方法及新型内镜外侧金属夹(over-the-scope clip,OTSC)对ANVUGIB患者的疗效,探讨OTSC用于ANVUGIB一线疗法的效果.结果 观察组止血有效率高于对照组(P<0.05),再出血率、输血率、住院时间低于对照组(P<0.05),但两组住院总费用差异无统计学意义(P>0.05).亚组分析中,OTSC止血操作时间、住院时间低于常规内镜治疗,但住院费用高于常规内镜治疗(P<0.05).在高危ANVUGIB患者中,OTSC止血有效率高、再出血率低(P<0.05),住院时间和住院费用差异无统计学意义(P>0.05).结论 消化内镜下止血在治疗ANVUGIB中效果显著,OTSC在高危ANVUGIB的一线治疗中效果更优.

A submucosal injection is usually required to improve the efficacy and safety of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR). This study aimed to evaluate the performance of 3.3% sodium carboxymethyl starch (Na-CMS) solution, a novel submucosal injection solution, for ESD and EMR. Na-CMS, normal saline (NS) and two commercially available agents (sigMAVisc and Eleview) were injected into the esophageal submucosa of randomly grouped pigs. The level of submucosal elevation was examined. Subsequently, ESD or EMR procedures using 3.3% Na-CMS or NS as submucosal injections were performed in the gastrointestinal tract of the pigs. Submucosal elevation was significantly higher and more sustained in the 3.3% Na-CMS group than in the controls ( P  < 0.05). The volume required for ESD or EMR was significantly lower in the 3.3% Na-CMS group than in the NS group (ESD: 12.21 ± 4.09 mL vs 28.25 ± 8.02 mL, P  < 0.001; EMR: 3.99 ± 1.98 mL vs 7.15 ± 3.67 mL, P = 0.001). The ESD resection time was significantly shorter in the 3.3% Na-CMS group than in the NS group (16.58 ± 7.30 min vs 25.29 ± 11.89 min, P = 0.004). Hemorrhage after ESD in the 3.3% Na-CMS group was less severe than that in the NS group ( P = 0.006). 3.3% Na-CMS is an effective, safe and low-cost submucosal injection solution and holds promise as preferable agent for submucosal injection in ESD and EMR procedures.

目的:探讨早期胃癌(early gastric cancer,EGC)内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)后发生迟发性出血风险的预测评分系统.方法:回顾性分析2016年2月-2020年11月在苏州大学附属第一医院消化科行ESD术治疗的296例EGC(包括高级别上皮内瘤变)患者的资料,经多因素分析找出影响EGC ESD术后迟发性出血的独立危险因素,并根据其回归系数对独立危险因素进行赋分,建立术后迟发性出血风险预测评分系统,且根据评分及迟发性出血发生率,绘制受试者工作特征曲线(receiver operating characteristic curve,ROC曲线),计算曲线下面积(area under the curve,AUC),根据评分进行危险分层.结果:病灶黏膜下层纤维化(OR=12.163,95％CI:2.735～54.102)、切除标本直径＞4 cm(OR=19.091,95％CI:3.726～97.819)、使用抗凝药和/或抗血小板药(OR=5.334,95％CI:1.013～28.088)是EGC ESD术后发生迟发性出血的独立危险因素(P均＜ 0.05);评分系统:使用抗凝药和/或抗血小板药为1分,病灶黏膜下层纤维化为2分,切除标本直径＞4 cm为2分.根据评分和迟发性出血发生率绘制ROC曲线,其AUC值为0.85 (95％CI:0.753～0.947,P＜ 0.001),最佳截断值为1.5分,以评分0～1分定义为低危组,评分2～5分定义为高危组,评分为低危组者ESD术后迟发性出血发生率为1.03％(2/194),评分为高危组者ESD术后迟发性出血发生率为16.67％(17/102),两组差异有统计学意义(x2=27.208,P＜ 0.001).结论:病灶黏膜下层纤维化、切除标本直径大于4 cm、使用抗凝药和/或抗血小板药,这3个独立危险因素构建的风险预测评分系统,能够有效识别EGC ESD术后发生迟发性出血的高风险患者.

Objective: To study the clinical characteristics and classification of gastric neuroendocrine neoplasm(NEN) and prognostic factors of mixed adenoneuroendocrine carcinoma (MANEC) and gastric neuroendocrine carcinoma(NEC). Methods: A total of 148 gastric NENs were divided into type Ⅰ, type Ⅱ and type Ⅲ based on the classification of European Neuroendocrine Tumor Society (ENETS). Kaplan-Meier test and Cox regression model were used in univariate and multivariate survival analysis in 108 cases with pathological G3 gastric NEN. Results: In this study, the percentages of type Ⅰ, type Ⅱ and type Ⅲ were 25.0%(37), 3.4%(5) and 71.6%(106) respectively. Among type Ⅰ patients, 28(75.7%) lesions were located in gastric fundus or body, 29(78.4%) had bumps. Lymph node involvement was found in 4 (10.8%) patients. Twenty-six (70.3%) patients received endoscopic treatment and 11 (29.7%) with surgery. All 5 type Ⅱ patients presented lesions in gastric fundus or body, including 4 with ulcers, who were all treated by endoscope. Three type Ⅱ patients had gastrinoma, and 2 combined with multiple endocrine neoplasmⅠ. In type Ⅲ patients, 56(52.8%) showed ulcerative lesions. The majority of patients (102, 96.2%) had a single lesion, 94(88.7%) with lymph node or other organ metastasis. In this study, no deaths were reported in gastric NEN with a pathological grade of G1 or G2. The mortality rate was 38.9%(42/108) in patients with G3 NEN. Survival analysis suggested that age, metastasis of tumor were associated with poor prognosis (P=0.041, 0.025). Conclusions: Patients with gastric NEN have heterogenous clinical presentations according to gender, age, endoscopic features, infiltration and metastasis, and pathological grade. Aging and metastasis are negative prognostic factors of G3 gastric NEN.