Objective To validate the efficacy of the prediction model for difficulty of peroral endoscopic myotomy (POEM) through an independent cohort. Methods A total of 617 patients with achalasia who underwent POEM at the Endoscopy Center of Zhongshan Hospital, Fudan University from January 2021 to December 2023 were included. The general data of patients were collected, and the predictive value of the prediction model for POEM difficulty in the validation cohort was estimated. The stratified analysis was undergone according to the difficulty risk scores. Results In 617 consecutive patients, technical difficulty was observed in 90 cases (14.6%). The predictive model demonstrated moderate discriminatory capacity with an area under the receiver operating characteristic curve (AUC) of 0.711 (95%CI 0.643-0.780). Patients were stratified into three risk categories according to the difficulty risk scores: low-risk (＜0.1), medium-risk (0.1-0.25), and high-risk (≥0.25). The corresponding technical difficulty rates were 7.3%, 16.9%, and 51.6%, respectively. Conclusion The prediction model for POEM difficulty built by our center shows good stability and discrimination, and has good clinical application value.

Gastrointestinal tumors are a serious and threatening public health concern.Endoscopic minimally invasive treatment is an im-portant way to achieve early diagnosis and treatment of gastrointestinal tumors.Here,we summarize the history and current status of en-doscopic minimally invasive resection of early-stage gastrointestinal tumors,and explain the application of the new ERBEC concepts of endo-scopic minimally invasive surgery for the treatment of gastrointestinal tumors,which include elements,reservation-resection,bilateral-bene-fit,expansion,and collaboration.We also discuss the future direction of endoscopic minimally invasive resection for gastrointestinal tumors.

Objective:To explore the efficacy and safety of endoscopic radial incision (ERI) for congenital membranous duodenal stenosis (MDS).Methods:The clinical data of 13 children with MDS receiving ERI in the Department of Gastroenterology of Xi'an Children's Hospital from May 2017 to December 2021 were reviewed and analyzed. The perioperative management, surgical procedures, postoperative complications and follow-up were summarized.Results:There were 5 boys and 8 girls with a median disease duration of 8 (2-20) months, and the median age of diagnosis was 13 months (5-30 months). The septum of 10 cases (10/13) was located in the descending part of the duodenum, and that of 3 cases (3/13) in the horizontal part. The papilla of 1 case (1/13) opened on the septum, that of 3 cases (3/13) within 5 cm of the mouth side of the septum, and that of 9 cases (9/13) within 5 cm of the anal side of the septum. The median diameter of the septal aperture was 3 mm (2-6 mm). All 13 children successfully underwent ERI with a median operation time of 20 min (15-32 min). The average surgical incision was 3 strokes (2-4 strokes), and the endoscope with outer diameter 9.9 mm could pass stenosis after ERI. The median incision diameter was 10 mm (10-12 mm). All patients achieved relief of clinical symptoms after ERI. One patient (1/13) suffered from the postoperative delayed bleeding, which was stopped by endoscopic titanium clamping. No intestinal perforation or duodenal papilla injury occurred, and median postoperative hospital stay was 6 days (5-10 days). The upper gastrointestinal angiogram and gastroscopy were repeated 3 months after ERI, and the median diameter of stenosis was 12 mm (10-15 mm), which was significantly dilated compared with before. The mean body weight increase at 1 month after ERI was 1.20 kg (0.50-1.80 kg), and the mean body weight increase at 3 months was 3.50 kg (2.50-4.00 kg), which reached the normal body weight of the same age.Conclusion:ERI is safe and effective for the treatment of MDS in children, and shows good clinical application and promotion value.

Objective:To investigate the diagnostic and therapeutic value of one-time biliopancreatic-duct-imaging-system (eyeMax)-assisted endoscopic retrograde appendicitis therapy (ERAT) for children.Methods:A total of 11 children who were diagnosed as having uncomplicated acute appendicitis by imaging in Xi′an Children′s Hospital from August to November 2022 were enrolled. All patients received subscope-assisted ERAT. Subscope was intubated into the appendix cavity to observe the mucosa directly. Appendicitis was treated through cleansing, fecalith extraction, stent drainage. The clinical manifestations under subscope were recorded, as well as the treatment success rate, intubation success rate, the effective rate, complication incidence during and after the operation.Results:The age of 11 children was 7.93±2.67 years old. Appendix intubation was successful in all patients. Congestion and swelling of the mucosa in appendiceal orifice and appendix cavity were seen under the subscope in 11 children. There were 6 cases with appendiceal fecaliths, 8 cases with pus and 6 cases with luminal distortion or stenosis. Perforation was observed in 1 case during the operation and no other complication occurred. All patients were treated under subscope, including flushing appendiceal cavity (11 cases), fecalith extraction with extraction basket (3 cases), and appendiceal drainage with stenting (2 cases). The symptoms and signs were relieved after the operation, and the effective rate within 48 hours was 10/11. There were no procedure-related complications or recurrence during postoperative follow-up for 1 week to 4 months.Conclusion:Acute appendicitis could be diagnosed by observing the appendix cavity directly under one-time biliopancreatic-duct-imaging-system-assisted ERAT, and also could be treated with the system, where appendix could be preserved and radiation damage could be avoided with safety and effectiveness.

Objective:To summarize the thoracic and abdominal CT presentations after endoscopic full-thickness resection (EFR) and to analyze its significance in the evaluation and management of postoperative complications.Methods:Data of 82 patients who underwent gastrointestinal EFR at the Endoscopy Center of Zhongshan Hospital, Fudan University and received a chest and/or abdominal CT within 1 week from September 2016 to September 2021 were collected retrospectively. The patients were divided into the intervention group ( n=38) and the control group ( n=44) according to the presence or absence of special postoperative interventions or prolonged hospital stays. The differences in the incidence of abnormal CT presentations between the two groups were analyzed. Risk factors for abnormal CT presentation were explored by multifactorial analysis. Results:Among the 82 patients, the main CT presentations were pneumoperitoneum in 51 patients (62.2%), abdominal and pelvic effusion in 30 patients (36.6%), pneumothorax in 5 (6.1%), pleural effusion in 43 (52.4%), and pulmonary inflammation in 16 (19.5%). The incidence of pelvic and abdominal effusions ( W=637.48, P=0.031) and pleural effusions ( W=622.06, P=0.031) in CT was higher in the intervention group than that in the control group. Age was an independent risk factor for air-related complications after EFR (>60 years old VS ≤60 years old: OR=0.17, 95% CI: 0.05-0.56, P=0.002). Conclusion:CT presentations of pelvic and abdominal effusion and pleural effusion after EFR is of great significance in suggesting complications, while patients with other CT presentations often do not require special intervention or prolonged hospital stay. Postoperative CT in elderly patients is less likely to detect air-related complications.

Background/Aims: Previous studies reveal that immune-mediated neuroinflammation plays a key role in the etiology of esophageal achalasia. However, the understanding of leucocyte phenotype and proportion is limited. This study aim to evaluate the phenotypes of leukocytes and peripheral blood mononuclear cells transcriptomes in esophageal achalasia. Methods: We performed high-dimensional flow cytometry to identified subsets of peripheral leukocytes, and further validated in lower esophageal sphincter histologically. RNA sequencing was applied to investigate the transcriptional changes in peripheral blood mononuclear cells of patients with achalasia. Cell-type Identification by Estimating Relative Subsets of RNA Transcripts (CIBERSORT) was used for estimating the immune cell types. A differential gene expression analysis was performed and the differential expressed genes were subjected to gene ontology, Kyoto Encyclopedia of Genes and Genomes network, protein-protein interaction network construction. Results: An imbalance between innate and adaptive immune cells occurred in achalasia. Specifically, neutrophils and CD8+ T cells increased both in peripheral blood and lower esophageal sphincter in achalasia. Eosinophils decreased in peripheral blood but massively infiltrated in lower esophageal sphincter. CIBERSORT analysis of peripheral blood mononuclear cells RNA sequencing displayed an increased prevalence of CD8+ T cells. 170 dysregulated genes were identified in achalasia, which were enriched in immune cells migration, immune response, etc. Proton pump inhibitor analysis revealed the intersections and gained 7 hub genes in achalasia, which were IL-6, Toll-like receptor 2, IL-1β, tumor necrosis factor, complement C3, and complement C1q A chain. Conclusion Patients with achalasia exhibited an imbalance of systematic innate and adaptive immunity, which may play an important role in the development of achalasia.

Objective:To investigate the safety and efficacy of submucosal tunnel docking endoscopic resection (SDER) for the treatment of giant submucosal tumors in the cardia.Methods:A retrospective analysis was performed on data of patients with giant submucosal tumors in the cardia who were treated with SDER at the endoscopy center of Zhongshan Hospital, Fudan University and Xuhui District Central Hospital from January 2021 to January 2022. The surgical records, postoperative pathology, complications, hospitalization, and follow-up were analyzed.Results:A total of 6 patients were included. The mean long diameter of the lesions was 4.0 cm, all of which were located in the cardia. All patients successfully underwent SDER treatment with a surgical time of 23-42 min. Postoperative pathology revealed that 4 cases were leiomyomas and 2 cases were gastrointestinal stromal tumors. All lesions were completely resected. The postoperative hospital stay was 3-5 d, and no serious complications occurred after surgery. All patients recovered on follow-up gastroscopy at 3 and 6 months postoperatively.Conclusion:The preliminary conclusion is that SDER for the treatment of giant submucosal tumors in the cardia is safe, effective.

To investigate the evaluation and management of gastrointestinal fistula after upper gastrointestinal tunnel endoscopic surgery, a retrospective analysis was performed on 15 patients with gastrointestinal fistula after upper gastrointestinal tunnel endoscopic surgery, who were treated at the Endoscopy Center of Zhongshan Hospital, Fudan University from January 2012 to October 2022. All patients were treated successfully after comprehensive treatment. Three patients received metal clipping and gastric tube drainage; 10 patients received gastric tube drainage combined with jejunal nutritional tube placement, and 7 of them had gastric tube directly put into the fistula cavity; 2 patients received covered esophageal stent placement combined with jejunal nutritional tube placement. Five patients received wound tissue glue spraying; 2 patients underwent purse-string suture with nylon loops and metal clips after reduced fistula burned by hot biopsy forcep or argon plasma coagulation. The gastrointestinal fistula after tunnel endoscopic surgery is a complex postoperative complication, which needs early detection, careful evaluation and comprehensive treatment.

Objective:To review publications in the field of digestive endoscopic minimally-invasive resection in the past 10 years in and outside China.Methods:Literature of digestive endoscopic minimally-invasive resection in the Web of Science and CNKI databases from January 1, 2011 to July 17, 2021 was retrieved. VOSviewer 1.6.11 was used for clustering and time series analysis of countries, institutions, authors and keywords, and drawing evidence-based visualization maps, so as to analyze the cooperation among countries, academic institutions and researchers, to compare the differences in research topics between Chinese and English databases, and to predict the future research hot spots and directions.Results:A total of 22 834 English articles and 4 636 Chinese articles were included. Over the past 10 years, the number of Chinese and English publications has been growing steadily, and most of them were published in professional journals. The publications were mainly from China, Japan, South Korea and the United States, where all exceeded 2 000. The National Cancer Center of Japan had 497 publications, ranking the first among all institutions. The cooperation between academic institutions showed obvious regional characteristics, and the inter-institutional and interpersonal cooperation needed improvement. In terms of keyword clustering, there was no significant difference between Chinese and English publications, but there were two additional clusters in Chinese publications, endoscopic nursing and submucosal tumor. Overlays analysis of key words showed that endoscopic surgery, tunneling technique, and submucosal tumor could be hot spots and future directions.Conclusion:Digestive endoscopic minimally-invasive resection has experienced a vigorous development in the past 10 years with a growing number of Chinese and English publications. China is playing an increasingly important role on the international stage. The advanced nature of research focus in Chinese publications is comparable to that in English publications, yet also showing Chinese characteristics. In the future, more efforts should be taken to strengthen regional cooperation and focus on research hot spots.

Objective:To evaluate high resolution esophageal manometry (HREM) in peroral endoscopic myotomy (POEM) for pediatric achalasia of cardia (AC).Methods:Data of 30 AC children who received POEM in Xi′an Children′s Hospital from January 2013 to September 2019 were reviewed. HREM was performed before and 6 months after POEM. Preoperative and postoperative lower esophageal sphincter pressure (LESP), 4-second integrated relaxation pressure (4sIRP), Eckardt scores and nutritional status were compared.Results:Children with AC aged between 4-14 years. Postoperative LESP was 5.50±1.13 mmHg (1 mmHg=0.133 kPa), which was significantly lower than that before operation (26.23±4.47 mmHg) with significant difference ( t=-24.623, P<0.001). Postoperative median 4sIRP was 5 mmHg, which was 20 mmHg lower than that before operation (25 mmHg) with significant difference ( Z=-4.786, P<0.001). Postoperative median Eckardt symptom score decreased significantly compared with that before (1 VS 8, Z=-4.796, P<0.001). Severe malnutrition of the AC children improved evidently to normal( Z=-5.166, P<0.001). Conclusion:POEM can significantly improve the characteristics of esophageal dynamics in children with AC, and HREM can be an important indicator for follow-up evaluation of POEM.