BACKGROUND:Accurate prediction of lymph node metastasis (LNM) is crucial for treatment decisions in early gastric cancer (EGC). Current preoperative methods for LNM prediction are often insufficient. PATIENTS AND METHODS:This multicenter retrospective study enrolled 605 EGC patients who underwent endoscopic submucosal dissection (ESD) and/or surgery across five institutions between 2013 and 2023. We developed a deep learning model, LNMate, to predict LNM before ESD and evaluated its impact on endoscopists' diagnostic performance. We also conducted immunohistochemical (IHC) analysis on tissue samples from 32 patients. Additionally, we constructed a deep learning-based endoscopic nomogram (DLEN) to estimate LNM risk after ESD, validated through comparison with the eCura system. RESULTS:LNMate showed high predictive performance with area under the curves (AUCs) ranging from 0.843 (95% confidence interval [CI], 0.782-0.904) to 0.875 (95% CI, 0.814-0.936). With LNMate assistance, endoscopists improved diagnostic accuracy by 13.8%, particularly in specificity (mean increase of 0.17, P = 0.03). IHC analysis showed associations between CD8+ and CD20+ cell enrichment with non-LNM predictions, and CD68+ macrophage infiltration with LNM. The DLEN outperformed the eCura system (AUC, 0.91 [95% CI, 0.86-0.97] vs. 0.71 [95% CI, 0.58-0.83], P < 0.01), reducing oversurgery by 24.2%, with no false negatives. CONCLUSIONS:The deep learning-based intelligent system for the entire treatment process of EGC showed excellent performance in predicting LNM, offering valuable decision support for both endoscopists in pre-ESD treatment planning and surgeons in post-ESD surgical decision-making.

Missed early gastric cancer (MEGC) is prevalent during esophagogastroduodenoscopy (EGD), which is the first-line recommended strategy for detecting early gastric cancer (EGC). Hence, we explored the risk factors for MEGC and different types of MEGC, based on the endoscopic resected population. This retrospective, case–control study was conducted at Nanjing Drum Tower Hospital (NJDTH). We included patients who were diagnosed with EGC during screening EGD, underwent endoscopic resection, and were confirmed by postoperative pathology at the NJDTH from January 2014 to December 2021, and classified them into different types according to the different root causes of misses. Univariable, multivariable, subgroup and propensity score analyses were used to explore the risk factors for MEGC and different types of MEGC. A total of 447 patients, comprising 345 with initially detected early gastric cancer (IDEGC) and 102 with MEGC, were included in this study. Larger size (≥ 1 cm) (OR 0.45, 95

Background Endoscopic submucosal dissection (ESD) is commonly used to treat early gastric cancer (EGC). The effects of Helicobacter pylori (HP) infection on ESD and the potential benefits of preoperative eradication of HP are unclear. We aimed to study the impact of HP infection on bleeding and lesion detection during ESD in these patients. Methods A total of 634 consecutive patients who underwent ESD for EGC at our centre from January 2018 to January 2023 were enrolled retrospectively. Logistic regression was used to analyze intraoperative bleeding and lesion detection rate based on HP eradication status. The screened indicators were used to create a predictive model, and efficacy was assessed using the ROC curve. Results HP-positive patients had a higher intraoperative bleeding rate (28.8%) compared with Hp-negative patients (8.9%) (P<0.001). HP-positive patients also had longer procedure time (median: 58.5 vs 50.0 minutes, P<0.001) and postoperative hospital stay (median: 4.35 vs 4.07 days, P=0.036) compared to HP-negative patients. Multivariate analysis revealed that HP-positive (OR=4.84), multiple lesions (OR=1.81), specimen size > 40 mm (OR=3.67), and submucosal invasion (OR=2.27) were independent risk factors for intraoperative bleeding (IDDF2024-ABS-0046 Figure 1). The predictive model had an AUC of 0.807 (95%CI=0.761-0.852) with a sensitivity of 72.1% and a specificity of 75.9% (IDDF2024-ABS-0046 Figure 2). Eradicating HP also increased the rate of lesion detection independently (OR=2.82). Conclusions HP eradication before ESD in patients with EGC reduces intraoperative bleeding and improves lesion detection. It is very necessary to eradicate HP before ESD for patients with EGC.

Background Endoscopic submucosal dissection (ESD) is commonly used to treat early gastric cancer (EGC). The effects of Helicobacter pylori (HP) infection on ESD and the potential benefits of preoperative eradication of HP remain unclear. The study aims to evaluate the impact of HP infection on bleeding and lesion detection during ESD in patients with EGC. Methods We retrospectively analyzed 634 consecutive patients who underwent ESD for EGC at our center between January 2018 and January 2023. Logistic regression was used to assess the impact of HP infection status on intraoperative bleeding and lesion detection rates. We developed a predictive model based on selected indicators and evaluated its performance using the ROC curve. Results HP-positive patients experienced a higher rate of intraoperative bleeding (28.8%) compared with HP-negative patients (8.9%) (P < 0.001). HP-positive patients also had longer procedure time (median: 58.5 vs. 50.0 min, P < 0.001) and postoperative hospital stays (median: 4.35 vs. 4.07 days, P = 0.036). Multivariate analysis identified HP-positive (OR = 4.84), multiple lesions (OR = 1.81), specimen size > 40 mm (OR = 3.67), and submucosal invasion (OR = 2.27) as independent risk factors for intraoperative bleeding. The predictive model achieved an AUC of 0.807 (95%CI 0.761-0.852), with a sensitivity of 72.1% and specificity of 75.9%. Preoperative HP eradication was associated with an increased rate of lesion detection (OR = 2.82). Conclusions Eradicating HP before ESD in patients with EGC reduces intraoperative bleeding and improves lesion detection. Preoperative HP eradication is therefore recommended in patients with EGC.

OBJECTIVE:To determine whether peroral endoscopic myotomy (POEM) improves esophageal peristalsis and to investigate the association between recovery of esophageal peristalsis after POEM and clinical features of the patients. METHODS:In this single-center retrospective study, data were collected from medical records of the patients with achalasia who underwent POEM between January 2014 and May 2016. Demographics data, high-resolution esophageal manometry parameters, Eckardt score, and gastroesophageal reflux disease questionnaire (GERD-Q) score were collected. Weak and fragmented contraction was defined as partial recovery of esophageal peristalsis based on the Chicago classification version 3.0. Logistic regression analysis was used to identify variables associated with the partial recovery of peristalsis after POEM. RESULTS:A total of 103 patients were enrolled. Esophageal contractile activity was observed in the distal two-thirds of the esophagus in 24 patients. The Eckardt score, integrated relaxation pressure, and lower esophageal sphincter (LES) resting pressure were significantly decreased after POEM. Multivariate analysis revealed that preprocedural LES resting pressure (P = 0.013) and preprocedural Eckardt score (P = 0.002) were related to the partial recovery of peristalsis after POEM. Symptoms of gastroesophageal reflux and reflux esophagitis after POEM were less frequent in those with partial recovery of peristalsis (both P < 0.05). CONCLUSIONS:Normalization of esophagogastric junction relaxation pressure achieved by POEM is associated with the partial recovery of esophageal peristalsis in patients with achalasia. Preprocedural LES resting pressure and the Eckardt score are predictive of the recovery of esophageal peristalsis.

To determine whether peroral endoscopic myotomy (POEM) improves esophageal peristalsis and to investigate the association between recovery of esophageal peristalsis after POEM and clinical features of the patients. In this single-center retrospective study, data were collected from medical records of the patients with achalasia who underwent POEM between January 2014 and May 2016. Demographics data, high-resolution esophageal manometry parameters, Eckardt score, and gastroesophageal reflux disease questionnaire (GERD-Q) score were collected. Weak and fragmented contraction was defined as partial recovery of esophageal peristalsis based on the Chicago classification version 3.0. Logistic regression analysis was used to identify variables associated with the partial recovery of peristalsis after POEM. A total of 103 patients were enrolled. Esophageal contractile activity was observed in the distal two-thirds of the esophagus in 24 patients. The Eckardt score, integrated relaxation pressure, and lower esophageal sphincter (LES) resting pressure were significantly decreased after POEM. Multivariate analysis revealed that preprocedural LES resting pressure ( P  = 0.013) and preprocedural Eckardt score ( P  = 0.002) were related to the partial recovery of peristalsis after POEM. Symptoms of gastroesophageal reflux and reflux esophagitis after POEM were less frequent in those with partial recovery of peristalsis (both P  < 0.05). Normalization of esophagogastric junction relaxation pressure achieved by POEM is associated with the partial recovery of esophageal peristalsis in patients with achalasia. Preprocedural LES resting pressure and the Eckardt score are predictive of the recovery of esophageal peristalsis.

Diagnosis of early gastric cancer (EGC) under narrow band imaging endoscopy (NBI) is dependent on expertise and skills. We aimed to elucidate whether artificial intelligence (AI) could diagnose EGC under NBI and evaluate the diagnostic assistance of the AI system. In this retrospective diagnostic study, 21,785 NBI images and 20 videos from five centers were divided into a training dataset (13,151 images, 810 patients), an internal validation dataset (7057 images, 283 patients), four external validation datasets (1577 images, 147 patients), and a video validation dataset (20 videos, 20 patients). All the images were labeled manually and used to train an AI system using You look only once v3 (YOLOv3). Next, the diagnostic performance of the AI system and endoscopists were compared and the diagnostic assistance of the AI system was assessed. The accuracy, sensitivity, specificity, and AUC were primary outcomes. The AI system diagnosed EGCs on validation datasets with AUCs of 0.888–0.951 and diagnosed all the EGCs (100.0%) in video dataset. The AI system achieved better diagnostic performance (accuracy, 93.2%, 95% CI, 90.0–94.9%) than senior (85.9%, 95% CI, 84.2–87.4%) and junior (79.5%, 95% CI, 77.8–81.0%) endoscopists. The AI system significantly enhanced the performance of endoscopists in senior (89.4%, 95% CI, 87.9–90.7%) and junior (84.9%, 95% CI, 83.4–86.3%) endoscopists. The NBI AI system outperformed the endoscopists and exerted potential assistant impact in EGC identification. Prospective validations are needed to evaluate the clinical reinforce of the system in real clinical practice.

Testicular mixed germ cell tumor is characterized by high degree of malignancy and prone to metastasis, the common of which is retroperitoneal lymph node metastasis. At present, EUS has a very important diagnostic value for mediastinal, enterocoelia and retroperitoneal lymph node metastasis of malignant tumors. It also has a positive value for the space occupying of parenchyma or cavity organ and can be used for the puncture operation of multiple lesions under real-time ultrasound monitoring with high safety and small complications.

Endoscopic submucosal dissection (ESD) for laterally spreading tumors (LST) involving the dentate line (LST-DL) is challenging because of the specific anatomical features of the anorectum. This study aimed to evaluate the efficacy and safety of ESD for LST-DL. Consecutive patients with LST-DL who had undergone ESD at our hospital between January 2010 and December 2015 were retrospectively enrolled in this study. Rates of en bloc resection, R0 resection, and complications, pathological characteristics, and tumor recurrence were analyzed and compared with those of LST in the rectum not involving the dentate line (LST-NDL). Altogether 49 patients with LST-DL (median age 63 years; 39 women; median lesion size 57 mm; median follow-up period of 24 months) and 96 patients with LST-NDL (median age 67 years; 31 women; median lesion size 47 mm; median follow-up period of 31 months) were enrolled. En bloc resection (93.9% [46/49] vs 94.8% [91/96]) and en bloc R0 resection rates (83.7% [41/49] vs 88.5% [85/96]), respectively, for LST-DL and LST-NDL, with no significant differences. However, ESD for LST-DL had a longer procedure time (77 min vs 54 min, P  = 0.02), a greater postprocedural perianal pain rate (28.6% vs 0%, P  < 0.001), and more anal strictures (4.1% vs 0%, P  = 0.04). The complication rates of perforation, bleeding and fever, recurrence rate, and pathological characteristics did not differ between the two groups. ESD is a safe and effective therapeutic modality for LST-DL. However, this procedure should be performed by experienced endoscopists and the difficulty needs to be fully considered.

ObjectiveEndoscopic submucosal dissection (ESD) for laterally spreading tumors (LST) involving the dentate line (LST‐DL) is challenging because of the specific anatomical features of the anorectum. This study aimed to evaluate the efficacy and safety of ESD for LST‐DL.MethodsConsecutive patients with LST‐DL who had undergone ESD at our hospital between January 2010 and December 2015 were retrospectively enrolled in this study. Rates of en bloc resection, R0 resection, and complications, pathological characteristics, and tumor recurrence were analyzed and compared with those of LST in the rectum not involving the dentate line (LST‐NDL).ResultsAltogether 49 patients with LST‐DL (median age 63 years; 39 women; median lesion size 57 mm; median follow‐up period of 24 months) and 96 patients with LST‐NDL (median age 67 years; 31 women; median lesion size 47 mm; median follow‐up period of 31 months) were enrolled. En bloc resection (93.9% [46/49] vs 94.8% [91/96]) and en bloc R0 resection rates (83.7% [41/49] vs 88.5% [85/96]), respectively, for LST‐DL and LST‐NDL, with no significant differences. However, ESD for LST‐DL had a longer procedure time (77 min vs 54 min, P = 0.02), a greater postprocedural perianal pain rate (28.6% vs 0%, P < 0.001), and more anal strictures (4.1% vs 0%, P = 0.04). The complication rates of perforation, bleeding and fever, recurrence rate, and pathological characteristics did not differ between the two groups.ConclusionsESD is a safe and effective therapeutic modality for LST‐DL. However, this procedure should be performed by experienced endoscopists and the difficulty needs to be fully considered.

Colorectal cancer (CRC) is the third most common malignancy and a leading cause of cancer-related death worldwide. GEF-H1 is considered a RhoA-specific guanine nucleotide exchange factor. GEF-H1 upregulation may contribute to cancer cell migration and invasion and tumor progression. However, the expression and role of GEF-H1 in CRC have not yet been elucidated. This study attempted to elucidate how GEF-H1 drives tumor formation, motility, invasion and metastasis in colon cancer (CC). The expression of GEF-H1 in CC tissue microarrays (TMAs) was analyzed by immunohistochemistry (IHC). GEF-H1 was upregulated in CC tissues compared with adjacent non-tumoral tissues. In addition, we found that high GEF-H1 expression correlated with shorter overall survival and distant metastasis. Migration and invasion assays showed that GEF-H1 upregulation increased CC cell motility, invasion and metastasis. In contrast, functional knockdown of GEF-H1 by RNAi rescued the effects caused by GEF-H1 overexpression in CC cells. Overexpression of GEF-H1 re-organized the actin cytoskeleton, with increased punctate paxillin staining and F-actin stress fibers. Furthermore, western blotting showed that RhoA activation triggered by GEF-H1 overexpression caused phosphorylation of its downstream target, MLC2, in CC cells. In summary, the present study revealed that GEF-H1 is upregulated in CC tissues and plays a key role in CC metastasis through the GEF-H1-RhoA-MLC2 signaling pathway.

Endoscopic submucosal dissection(ESD) has been rapidly gaining popularity worldwide recently due to high en bloc resection rate, minimally invasive procedure, patient rapid recovery and reduced health-care cost. However, ESD is associated with more complications, such as bleeding and perforation, especially in esophageal cases without good visualization of the dissection layer. Therefore, the efficacy and safety of snare traction for ESD of early esophageal carcinoma (EEC) or precancerous lesions was investigated. 57 EEC or precancerous patients were enrolled in the study and randomly divided into two groups . 26 cases underwent ESD with snare traction (snare group). In snare group, a snare was clamped to the oral side of the lesion after the circumferential incision and pushed in the anal direction during ESD. 31 cases underwent routine ESD without snare traction (non-snare group). The total dissection time, en bloc resection rate , average dissection area per minute, times of muscularis propria injury and incidence of perforation were statistically analyzed. ESD was successful in all 57 cases with 100% en bloc resection and there was no perforation during ESD or after ESD in all these cases. No significant difference was found between the two groups with respect to the dissection area (17.01±8.42cm2 vs 17.41±7.08cm2, P>0.1). The total dissection time of ESD was shorter in the snare group than in the non-snare group (57.10±9.65min vs 87.12±10.24min，P<0.05) . The average dissection area per minute is higher in the snare group than in the non-snare group(29.78±7.06 mm2/min vs 18.44±6.58mm2/min, P<0.05).Moreover, the muscularis propria injuries in the snare group were obviously less than the non-snare group (1.32±1.06 vs 2.50±1.12，P<0.05). Snare traction is potential for decreasing the injury of muscularis propria layer and total dissection time during ESD for esophageal cancerous lesions with easy control. It could be recommended as a safe and effective procedure for ESD of EEC and precancerous lesions.

We developed a novel method of endoscopic subserosal dissection (ESSD) for removal of subepithelial tumors (SETs) originating from the muscularis propria (MP) layer in the upper gastrointestinal (GI) tract. The aim of this study was to evaluate the efficacy, safety, and clinical outcome of this method.

ObjectiveTo investigate the outcomes of Chinese Han patients who underwent peroral endoscopic myotomy (POEM) for achalasia.MethodsPatients undergoing POEM for achalasia at the Affiliated Drum Tower Hospital of Nanjing University Medical School were prospectively enrolled in this study, with a follow‐up duration of at least one year. Their outcomes were evaluated by analyzing esophageal manometry, timed barium esophagogram and 36‐Item Short Form Health Survey (SF‐36), which were performed before surgery, 5 days after surgery and at the last follow‐up. Patients' symptom relief was considered the primary outcome. Secondary outcomes included lower esophageal sphincter (LES) pressure, esophageal emptying, patients' quality of life (QoL) and procedure‐related complications.ResultsEighty‐seven patients were included in the study. Eckardt score after POEM was remarkably lower than the preoperative score (0.4 ± 0.7 vs 7.1 ± 2.1, P = 0.001). The preoperative LES pressure was 32.4 ± 15.3 mmHg, which was decreased to 3.8 ± 3.9 mmHg immediately after surgery. The height of the barium column at 1 min after barium swallow was significantly reduced after treatment (11.7 ± 1.2 cm vs 3.2 ± 1.6 cm, P < 0.001). The patients' QoL was also improved, as indicated by obviously increased physical and mental component summary (PCS and MCS) scores of the SF‐36. Complications occurred during POEM included cutaneous emphysema, mucosal injury and pneumothorax.ConclusionPOEM is an effective approach for treating achalasia, which can relieve the symptoms of achalasia by improving esophageal emptying and lowering LES pressure.