Non-invasive laparoscopic detection of small tumors of the digestive tract using inductive sensors of proximity

The precise location of gastric and colorectal tumors is of paramount importance for the oncological surgeon as it dictates the limits of resection and the extent of lymphadenectomy. However, this task proves sometimes to be very challenging, especially in the laparoscopic setting when the tumors are small, have a soft texture, and do not invade the serosa. In this view, our research team has developed a new instrument adapted to minimally-invasive surgery, and manipulated solely by the operating surgeon which has the potential to locate precisely tumors of the digestive tract. It consists of an inductive proximity sensor and an electronic block encapsulated into an autoclavable stainless-steel cage that works in tandem with an endoscopic hemostatic clip whose structure was modified to increase detectability. By scanning the serosal side of the colon or stomach, the instrument is capable to accurately pinpoint the location of the clip placed previously during diagnostic endoscopy on the normal bowel mucosa, adjacent to the tumor. In the current in-vivo experiments performed on large animals, the modified clips were transported without difficulties to the point of interest and attached to the mucosa of the bowel. Using a laparoscopic approach, the detection rate of this system reached 65% when the sensor scanned the bowel at a speed of 0.3 cm/s, and applying slight pressure on the serosa. This value increased to 95% when the sensor was guided directly on the point of clip attachment. The detection rate dropped sharply when the scanning speed exceeded 1 cm/s and when the sensor-clip distance exceeded the cut-off value of 3 mm. In conclusion, the proposed detection system demonstrated its potential to offer a swift and convenient solution for the digestive laparoscopic surgeons, however its detection range still needs to be improved to render it useful for the clinical setting.

Endoscopic Ultrasonography in Children with Eosinophilic Esophagitis—A Review

Endoscopic ultrasonography (EUS) is a diagnostic endoscopy of the upper gastrointestinal tract, during which ultrasound of nearby organs is also performed. It is also possible to perform a fine needle aspiration biopsy. Currently, EUS is performed more frequently in adults. Despite some limitations, this diagnostic method is also more and more often performed in pediatric patients. Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus, which also occurs in children, and leads to irreversible fibrosis of the esophagus wall, if left untreated. Traditional methods of diagnosing and monitoring EoE treatment have significant limitations, and the use of EUS and total esophageal wall thickness (TWT) assessment may bring measurable benefits. Several studies have shown an increased thickening of TWT in EoE in children compared to pediatric patients with gastroesophageal reflux disease, and a decrease in TWT in adults who responded to EoE treatment. These results suggest that EUS and TWT measurement may become an important test in diagnostics, monitoring the effectiveness of therapy, assessing disease progression, and in individualizing the method and duration of EoE treatment also in children.

Deleterious Genetic Variation Across the NOD Signaling Pathway Is Associated With Reduced NFKB Signaling Transcription and Upregulation of Alternative Inflammatory Transcripts in Pediatric Inflammatory Bowel Disease

Background Inflammatory bowel disease may arise with inadequate immune response to intestinal bacteria. NOD2 is an established gene in Crohn’s disease pathogenesis, with deleterious variation associated with reduced NFKB signaling. We hypothesized that deleterious variation across the NOD2 signaling pathway impacts on transcription. Methods Treatment-naïve pediatric inflammatory bowel disease patients had ileal biopsies for targeted autoimmune RNA-sequencing and blood for whole exome sequencing collected at diagnostic endoscopy. Utilizing GenePy, a per-individual, per-gene score, genes within the NOD signaling pathway were assigned a quantitative score representing total variant burden. Where multiple genes formed complexes, GenePy scores were summed to create a “complex” score. Normalized transcript expression of 95 genes within this pathway was retrieved. Regression analysis was performed to determine the impact of genomic variation on gene transcription. Results Thirty-nine patients were included. Limited clustering of patients based on NOD signaling transcripts was related to underlying genomic variation. Patients harboring deleterious variation in NOD2 had reduced NOD2 (β = -0.702, P = 4.3 × 10-5) and increased NFKBIA (β = 0.486, P = .001), reflecting reduced NFKB signal activation. Deleterious variation in the NOD2-RIPK2 complex was associated with increased NLRP3 (β = 0.8, P = 3.1475 × 10-8) and TXN (β = -0.417, P = 8.4 × 10-5) transcription, components of the NLRP3 inflammasome. Deleterious variation in the TAK1-TAB complex resulted in reduced MAPK14 transcription (β = -0.677, P = 1.7 × 10-5), a key signal transduction protein in the NOD2 signaling cascade and increased IFNA1 (β = 0.479, P = .001), indicating reduced transcription of NFKB activators and alternative interferon transcription in these patients. Conclusions Data integration identified perturbation of NOD2 signaling transcription correlated with genomic variation. A hypoimmune NFKB signaling transcription response was observed. Alternative inflammatory pathways were activated and may represent therapeutic targets in specific patients.

SP7.1.16 Endoscopy and biopsy for chronic diarrhoea: an audit and cost analysis

Aims The aim of the study is to analyse the costs of performing diagnostic endoscopy with histopathological sampling for patients suffering with chronic or persistent diarrhoea. Methods 300 patients were identified who required an endoscopy in 2019 according to the British Society of Gastroenterology guidelines. Patient’s presenting complaint, endoscopic and histological diagnosis and follow up plans were noted. 147 patients were included into our study whose presenting complaint was solely chronic or persistent diarrhoea. Those who presented with acute diarrhoea, PR bleeding or other concomitant indication for lower gastrointestinal endoscopy were excluded. Data from the national schedule of NHS costs was used to calculate expenditure. Results The total expenditure calculated for the 147 patients was £55,973. There was a total of 126 colonoscopies and 21 flexible sigmoidoscopies performed by the department. The number of patients who received medical treatment following endoscopy was 13/147 (9%) 8 of whom had nonspecific colitis on histology. There were 29 patients (20%) who required symptomatic treatment and there were 98 patients (66%) who received no intervention or were discharged immediately and 7 patients (5%) that required surgical intervention. The total cost of procedures not leading to surgical or medical management with steroids or immunomodulators was £47733 which is 85.3% of the total expenditure. Conclusion A significantly large proportion of investigations lead to no intervention or symptomatic treatment of the patient. Given this lack of diagnostic yield and financial burden, there could be room for advancement in the current guidelines for managing persistent diarrhoea.

A Case of Tuberculosis Lymphadenitis Mimicking Gastric Tumor

Introduction: Solitary tuberculosis of the upper gastrointestinal tract is a rare pathology that usually mimics the clinical and radiological features of malignant tumors. A gastric subepithelial tumor is usually detected during diagnostic endoscopy. Stomach tuberculosis, in particular, can appear as a subepithelial tumor of the stomach wall. Several cases of gastric tuberculosis imitating subepithelial tumor gastric have been reported recently. Case report: We describe a case of a Patient with tuberculous lymphadenitis that mimics the submucosal gastric tumor. A 52-year-old female was admitted to our department; endoscopy revealed a submucosal compression or anterior submucosal lesion, erosive anterior gastropathy, and a fistulous orifice located in the bulb. The patient was diagnosed with a gastric tumor and Endoscopic ultrasound demonstrated a rounded antral lesion, hypoechogenic, not vascularized, that is distant from the gastric wall whose 5 layers appear of normal aspect. The patient was operated on for exploratory laparotomy. the biopsy was sent for frozen section examination that concluded to tuberculous intraperitoneal lymphadenitis. The patient received anti-tuberculosis treatment.Conclusion: Abdominal lymphadenitis tuberculosis is an uncommon situation which presents a dilemma for clinicians, as a great mimicker for a long list of differential diagnoses.

Detection of Factors That Cause Delay to Surgical Treatment of Patients with Gastrointestinal Malignancies in Patients of Hospital during 2 Years

Background: Many patients with gastrointestinal malignancies suffer from false treatments and incorrect diagnostic studies before diagnosis. This study examines the time taken to diagnose gastrointestinal cancer, identify the cause of delay, and judge its clinical importance. Materials and Methods: Patients with gastrointestinal malignancies (Esophageal, gastric, and colorectal) who were admitted for the first surgery were considered. The delay of diagnosis and treatment and responsible factors were analyzed from patients' history by recall of patients and reviewing para-clinical data, patient's records, and pathology report. Results: A total of 123 patients underwent diagnostic endoscopy 140 times. This study shows that the rate of biopsy in the three groups of patients with esophageal, gastric and colorectal cancers was 0.8%, 11.4% and 87.8%, respectively, which was not significantly different. A comparison of the number of patients who have undergone endoscopy more than once in the three groups of esophageal, gastric and colorectal malignancies shows that 6% of patients with esophageal cancer and 12% of patients with gastric cancer have undergone endoscopy more than once. This rate was 82%% in patients with colorectal cancer (P Value = 0.05). Conclusion: from this study can we educate the public about the symptoms of these diseases; and work that can be offered as a suggestion in this field, in prioritizing surgeries related to malignancies referred to medical centers, as well as establishing a systemic management of the initial diagnosis and finally treatment leading to surgery in patients with malignancies in each classification is.

Accuracy of Preoperative Endoscopy in Determining Tumor Location Required for Surgical Planning for Esophagogastric Junction Cancer

Purpose: The surgical strategy for esophagogastric junction (EGJ) cancer depends on the tumor location as measured relative to the EGJ line. The purpose of this study was to clarify the accuracy of diagnostic endoscopy in different clinicopathological backgrounds. Methods: Subjects were 74 consecutive patients with abdominal esophagus to upper gastric cancer who underwent surgical resection. Image-enhanced endoscopy with narrow-band imaging (NBI) was used to determine the EGJ line, prioritizing the presence of palisade vessels, followed by the upper end of gastric folds, as a landmark. The relative positional relationship between the tumor epicenter and the EGJ line was classified into six categories, and the agreement between endoscopic and pathologic diagnoses was examined to evaluate prediction accuracy. Results: The concordance rate of 69 eligible cases was 87% with a kappa coefficient (K) of 0.81. The palisade vessels were observed in 62/69 patients (89.9%). Of the 37 pathological EGJ cancers centered within 2 cm above and below the EGJ line, Barrett’s esophagus was found to be a significant risk factor for discordance (risk ratio, 4.40; p = 0.042); the concordance rate of 60% (K = 0.50) in the Barrett’s esophagus group was lower than the rate of 91% (K = 0.84) in the non-Barrett’s esophagus group. In five of six discordant cases, the EGJ line was estimated to be proximal to the actual line. Conclusion: Diagnostic endoscopy is beneficial for estimating the location of EGJ cancer, with a risk of underestimating esophageal invasion length in patients with Barrett’s esophagus.

Development of EndoScreen Chip, a Microfluidic Pre-Endoscopy Triage Test for Esophageal Adenocarcinoma

The current endoscopy and biopsy diagnosis of esophageal adenocarcinoma (EAC) and its premalignant condition Barrett’s esophagus (BE) is not cost-effective. To enable EAC screening and patient triaging for endoscopy, we developed a microfluidic lectin immunoassay, the EndoScreen Chip, which allows sensitive multiplex serum biomarker measurements. Here, we report the proof-of-concept deployment for the EAC biomarker Jacalin lectin binding complement C9 (JAC-C9), which we previously discovered and validated by mass spectrometry. A monoclonal C9 antibody (m26 3C9) was generated and validated in microplate ELISA, and then deployed for JAC-C9 measurement on EndoScreen Chip. Cohort evaluation (n = 46) confirmed the expected elevation of serum JAC-C9 in EAC, along with elevated total serum C9 level. Next, we asked if the small panel of serum biomarkers improves detection of EAC in this cohort when used in conjunction with patient risk factors (age, body mass index and heartburn history). Using logistic regression modeling, we found that serum C9 and JAC-C9 significantly improved EAC prediction from AUROC of 0.838 to 0.931, with JAC-C9 strongly predictive of EAC (vs. BE OR = 4.6, 95% CI: 1.6–15.6, p = 0.014; vs. Healthy OR = 4.1, 95% CI: 1.2–13.7, p = 0.024). This proof-of-concept study confirms the microfluidic EndoScreen Chip technology and supports the potential utility of blood biomarkers in improving triaging for diagnostic endoscopy. Future work will expand the number of markers on EndoScreen Chip from our list of validated EAC biomarkers.