Introduction

Recently, various electrosurgical knives with water-jet functions are available worldwide. However, their injection performances using water-jet functions have not been objectively evaluated thus far.

Aims & Methods

This study aimed to objectively evaluate the water-jet-functioned electrosurgical knife injection performances in a desktop experiment.Five types of water-jet-functioned electrosurgical knives, including two injection styles of sheath-type (A: DualKnife J, KD-655L; B: FlushKnife, DK2620-J-B20S; C: Splash M-Knife, DN-D2718B; D: ISSEN, SN1650-20) and tip-type (E: ORISE ProKnife, M00519361) were evaluated. These knives were compared with an injection needle (Control: SuperGrip 25G) as a control. The injection speed under constant pressure and the injection efficiency for each knife against prepared porcine stomach mucosa were evaluated. The additional clear gel injections using an injection needle were observed using an indigo blue-colored gel to evaluate the difference between the locations of water-jet holes.

Results

Four types of knives, except for A, showed significantly higher water-jet speeds (A: 0.79 ± 0.03 g/20 sec, B: 2.56 ± 0.05 g/20 sec, C: 3.09 ± 0.06 g/20 sec, D: 2.86 ± 0.05 g/20sec, E: 1.79 ± 0.03 g/20 sec) compared to that of the control (1.21 ± 0.03 g/20 sec). Meanwhile, significantly higher efficacy of injection was found in the tip-type water-jet function knife, second to the injection needle (Control: 37.2% ± 35.5%, A: 20.9% ± 20.2%, B: 1.1% ± 2.2%, C: 6.2% ± 12.6%, D: 12.5% ± 15.6%, E: 33.3% ± 32.2%). An additional injection experiment revealed that the injection with a piercing tip into the gel could achieve sufficient additional injection inside the stacked clear gel.

Conclusion

The tip-type water-jet function electrosurgical knife is preferable for effective submucosal injection during endoscopic treatments.

Introduction

Recurrence of Crohn’s disease (CD) after ileocolic resection is common. However, reliable non-invasive monitoring methods are lacking, for instance, the use of faecal calprotectin (FC) has showed inconsistent results in this subgroup of patients.

Aims & Methods

The aim of this study was to evaluate clinical and biochemical factors associated with post-operative endoscopic recurrence in CD patients.
Retrospective single-center study including patients with CD who underwent ileocolonoscopy for CD surveillance, after ileocolic resection. The patients’ clinical status was evaluated through Harvey-Bradshaw index (HBI), with clinical remission considered as ≤ 4 points. Biochemical parameters included erythrocyte sedimentation rate (ESR), c-reactive protein (CRP) and FC. Clinical and biochemical parameters were evaluated in the 6 months prior to ileocolonoscopy. Post-operative endoscopic recurrence was defined as a Rutgeerts score ≥ i2b.

Results

A total of 81 patients and 121 ileocolonoscopies were included. Most patients were female (55.6%), with a mean age of 48±13 years. Regarding the Montreal classification, 37 patients had ileal disease (45.7%) and 44 ileocolonic disease (54.3%); 9 patients had nonstricturing, nonpenetrating disease (11.1%), 35 stricturing (43.2%) and 37 penetrating disease (45.7%). Nineteen patients had perianal disease (23.5%). The mean time between the surgery and the endoscopic evaluation was 135±79 months. Post-operative endoscopic recurrence was observed in 52 ileocolonoscopies (43.0%).
Symptomatic patients (HBI > 4 points) were 11 times more likely to have post-operative endoscopic recurrence (OR 10.686, 95%CI 2.930-38.974, p<0.001). Those with post-operative endoscopic recurrence had a significantly higher FC values (median 189 vs 69 µg/g, p<0.001) and higher ESR values (median 14 vs 9 mm, p=0.002). In fact, patients with FC values ≥ 150 µg/g and those with ESR values > 12 mm were 4 and 3 times more likely to have post-operative endoscopic recurrence (OR 3.654, 95%CI 1.605-8.316, p=0.002 and OR 3.059, 95%CI 1.397-6.696, p=0.005, respectively). The presence of post-operative endoscopic recurrence was not associated with CRP values (median 2.9 vs 2.9 mg/L, p=0.466), and neither with mean time between the surgery and the endoscopic evaluation (mean 126±83 vs 142±75 months, p=0.263).

Conclusion

The presence of symptoms (HBI > 4 points), FC values ≥ 150 µg/g and ESR values > 12 mm was associated with post-operative endoscopic recurrence in CD. Therefore, the HBI, FC and ESR values can be used to monitor CD patients after ileocolic resection, and prompt endoscopic evaluation should be performed in those with HBI > 4 points, FC values ≥ 150 µg/g and/or ESR values > 12 mm.

Introduction

Endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for hepatic solid lesions has emerged as a safe technique to obtain an adequate liver tissue for diagnosis of parenchymal liver disease. However, the optimal FNB techniques have not been evaluated. Out study aimed to compare the diagnostic yield and specimen adequacy for EUS-FNB in hepatic solid lesions using different FNB techniques.

Aims & Methods

This is a single center retrospective study of EUS-FNB for hepatic solid lesions between Mar. 2015 and Jun. 2022. Each one needle pass of suction and slow-pull suction was applied for the same hepatic lesions and the sequence was randomly assigned. The primary outcomes were diagnostic yield to attain a histological diagnosis and rate of adequate specimen acquisition.

Results

A total of 119 patients (40 female, median age 70 years) underwent EUS-FNB for hepatic solid lesions. The mean size of hepatic solid lesion was 34.9+27.3 mm (range 7-150). Solid live lesions were located at S1 in 5 (4.2%), S2/3 in 97 (81.5%), S4 in 13 (10.9%), and S5/6/7/8 in 4 (3.3%). Needle puncture was approached at esophagus in 5 (4.2%), stomach in 108 (90.8%), and duodenum in 6 (5.0%). The use of needle was 20G ProCore in 44 (37.0%) and 22G in 75 (63.0%). The final diagnosis of solid liver lesions was benign in 3 (2.5%) and malignancy in 116 (97.5%) including cholangiocarcinoma (49, 41.2%), metastasis (63, 52.9%), hepatocellular carcinoma (2, 1.7%), and lymphoma (2, 1.7%). The overall diagnostic yield to obtain a tissue diagnosis was 90.8%. There was statistically no difference in diagnostic accuracy between suction and slow-pull suction (79.8% vs. 84.9%, P=0.308). Slow-pull suction obtained more adequate specimen comparing to suction (95.0% vs. 87.4%, P=0.040).

Table 1. Comparison of specimen adequacy and diagnostic performances according to EUS-FNB techniques

Conclusion

The use of slow-pull suction EUS-FNB demonstrated improved specimen adequacy compared with suction technique with no difference in diagnostic accuracy.

References

Madhok, I. K., et al. (2022). "Endoscopic Ultrasound-Guided Liver Biopsy." Clin Liver Dis 26(1): 127-138.
Gheorghiu, M., et al. (2022). "Endoscopic Ultrasound-Guided Fine-Needle Biopsy versus Fine-Needle Aspiration in the Diagnosis of Focal Liver Lesions: Prospective Head-to-Head Comparison." Diagnostics (Basel) 12(9).

Introduction

Endoscopic ultrasound (EUS) is an important tool for the evaluation of patients with common bile duct (CBD) dilation without obvious identified aetiology after ultrasonography (US), computed tomography (CT) and/or magnetic resonance cholangiopancreatography (MRCP).

Aims & Methods

The aim of this study was to evaluate the diagnostic performance of EUS for CBD dilation in patients with a negative initial study.
Retrospective, unicentric and cohort study including patients who underwent EUS for CBD dilation (diameter ≥7mm if intact anatomy or ≥10mm if prior cholecystectomy) in the absence of obvious pathology on prior imaging, including US, CT and/or MRCP, from January 2016 until June 2022. All EUS procedures were performed with a linear echoendoscope.

Results

Totally, 109 patients were included, 50 patients without symptoms or altered liver biochemistry (45.9%). Among the 41 patients with positive EUS, 33 patients had choledocholithiasis (30.3%), 6 chronic pancreatitis (5.5%) and 2 had ampullary cancer (1.8%). Older age was associated with positive EUS (median 79 vs 71 years, p=0.030). Patients with jaundice, cholelithiasis and altered liver biochemistry were 16.2 (p=0.002), 3.1 (p=0.024) and 2.9 (p=0.009) times more likely to have positive EUS, respectively.
A total of 53 patients underwent MRCP with a negative result (48.6%). In this group, 12 patients had a positive EUS, 10 had choledocholithiasis (18.9%) and 2 had chronic pancreatitis (3.8%). Of those, patients with abdominal pain and jaundice were 15.4 (p<0.001) and 20.0 (p=0.007) times more likely to have positive EUS, respectively. CBD diameter in MRCP was not associated with finding a causative lesion (p=0.473).
Considering only asymptomatic patients without altered liver biochemistry, CBD diameter ≥8.5mm, evaluated by CT, had a sensibility of 100% and specificity of 75% in predicting a positive EUS (AUC 0.734, p=0.048).

Conclusion

EUS is a useful diagnostic method for patients with unexplained CBD dilation, with a higher yield, even in patients with negative MRCP, and especially in patients with older age, symptoms such as abdominal pain and jaundice, cholelithiasis and/or altered liver biochemistry. CBD diameter evaluated by CT had a moderate discriminative ability in predicting a positive EUS in asymptomatic patients without altered liver biochemistry.

Introduction

Recent genomic analysis of biliary tract carcinoma has revealed the distinct genetic features based on their primary sites and is expected to help develop primary site-specific treatments. However, the exact primary site of perihilar cholangiocarcinoma (phCCA), which is located between the intrahepatic and extrahepatic bile ducts, is virtually unknown. A precise diagnosis of the primary tumor site of phCCA is urgently necessary to select appropriate treatment and improve prognosis.

Aims & Methods

This study aims to identify the primary site of phCCA by molecular pathological analysis. We analyzed a total of 358 surgically treated invasive CCA operated at the National Cancer Centre Central Hospital Tokyo, Japan from 1990 to 2013. The primary site of the tumor was evaluated based on bile duct stenosis location on preoperative image findings, detailed macroscopic observation in the resected specimen and histological tumor localization using elastic fiber staining. Hilar CCA (hCCA) was defined as a tumor originating in the upper common, right or left hepatic duct without macroscopic mass formation in liver. The analysis set included 39 cases of mass-forming type intrahepatic CCA (iCCA-MF) and 9 cases of extrahepatic CCA (eCCA) in which both frozen and formalin-fixed paraffin-embedded specimens were available. The validation set included 60, 100, 85, 14, 36, and 15 cases of iCCA-MF, eCCA, hCCA, periductal infiltrating intrahepatic CCA (iCCA-PI), periductal infiltrating plus mass-forming intrahepatic CCA (iCCA-PI+Mass), and iCCA-MF with perihilar invasion, respectively. First, transcriptome analysis was performed using the analysis set to identify candidate genes differentially expressed between eCCA and iCCA-MF. Second, immunohistochemical staining of the candidate genes was performed on the analysis set to determine the evaluation criteria. Finally, immunostaining of the candidate markers was performed on the validation set to evaluate the expression levels of each CCA subtype and statistically analyze the comparison between hCCA and the other CCA subtypes.

Results

Candidate genes included Serpin Family A Member 1 (SEPRINA1), Claudin18 (CLDN18), and Mesothelin (MSLN) as positive cases, with their immunohistochemical staining evaluation criteria of ≥33%, ≥5%, and ≥1+ (positive intensity), respectively. The immunohistochemical expression of each three molecules in the analysis set between eCCA and iCCA-MF revealed SERPINA1 at 0% vs. 82% (P < 0.01), CLDN18 at 100% vs. 41% (P < 0.01), and MSLN at 100% vs. 48% (P < 0.01). Similarly, a statistically significant difference was observed in the expression of each of the three molecules in the validation set. However, no significant difference was found in the immunohistochemical expression of the three molecules between eCCA and hCCA. Conversely, SERPINA1 expression in iCCA-MF cases with perihilar invasion was significantly different from that in cases of hCCA with microscopic hepatic parenchyma invasion, but not significantly different from that in cases of iCCA-PI+Mass. Furthermore, clustering analysis of the combination of three molecule expressions revealed that CCA was divided into three subgroups, consisting of iCCA-MF, iCCA-PI+Mass and iCCA-PI, and hCCA and eCCA.

Conclusion

We demonstrated molecular pathologically that the primary tumor site of phCCA can be identified and clinicopathologically classified in detail. In particular, we succeeded in showing that hCCA is classified into the same group as eCCA.

Introduction

The use of 3D cell culture models, including spheroids and organoids, has proven to be a valuable method to approximate in vivo conditions in basic research. Our recent work on the pathogenesis of spontaneous bacterial peritonitis (SBP) – a life-threatening complication of liver cirrhosis with a 1-year-mortality of 66% – shows that bacteria induce the degradation of important cell-cell contact proteins upon direct contact via various processes. The resulting destabilization of the epithelial barrier enables bacterial translocation and thus represents a mechanism in the development of SBP (Haderer et al., Gut 2022). To evaluate these processes under more physiological conditions, we investigate bacterial-induced effects on cell-cell contact proteins in a 3D spheroid model and subsequently in a patient-based organoid model.

Aims & Methods

To establish the method and create a reference, spheroids were generated from colon carcinoma cell line HCT116 with a concentration of 70,000 cells/ml. Spheroid development and formation of cell-cell contacts were assessed by fluorescence microscopy. Subsequently, bacterial-induced effects on the tight junction proteins Occludin, Claudin4 and Zonulin1 as well as on the adherens junction protein E-Cadherin were investigated after up to 12 hours of bacterial co-culture using qPCR, fluorescence microscopy and Western blot analysis. Bacterial co-culture was performed with the reference strain Escherichia coli (E.coli) O6:Hnt and the E. coli strain Ont:H41, which was isolated from the ascites of a patient with SBP.
In addition, organoids were generated from intestinal biopsies of patients with liver cirrhosis and co-cultured with both bacterial strains. Bacterial-induced effects on cell-cell-contact proteins were investigated using Western blot analysis.

Results

HCT116 cells formed formed spheroids composed of viable cells with well-defined cell-cell contacts. Co-culture with E. coli for up to 12 hours led to a significant degradation of Occludin (up to 60% reduction), E-Cadherin (up to 85% reduction) and Zonulin1 (up to 95% reduction), whereas Claudin4 levels remained mostly constant. Co-culture with heat-inactivated bacteria did not affect cell-cell contacts. The intensity of these effects was dependent on the respective protein, the bacterial strain used, as well as the multiplicity of infection (MOI) and the duration of the co-culture. Degradation of Occludin could also be visualized by fluorescence microscopy.
We were then able to transfer this experimental approach to an organoid setting. Bacterial-induced degradation of the epithelial barrier was confirmed in organoids, showing a clearly visible reduction of E-Cadherin, Occludin and Zonulin1 after 8 hours of bacterial co-culture. The intensity of the effects varied depending on the bacterial strain, with the patient strain showing a slightly higher level of aggressiveness.

Conclusion

Understanding the pathophysiological changes of the intestinal epithelial barrier in patients with liver cirrhosis is essential for advancing therapeutic strategies for SBP. In this context, a representative ex vivo model is crucial to draw reliable conclusions. Our work shows that relevant mechanisms of SBP, such as bacterial-induced degradation of cell-cell contacts, can be successfully modeled in spheroids and organoids. Thus, our study provides an approach for further approximation to in vivo conditions – bridging the gap between basic research and clinical utility.

References

Haderer M, Neubert P, Rinner E, Scholtis A, Broncy L, Gschwendtner H, Kandulski A, Pavel V, Mehrl A, Brochhausen C, Schlosser S, Gülow K, Kunst C, Müller M. Novel pathomechanism for spontaneous bacterial peritonitis: disruption of cell junctions by cellular and bacterial proteases. Gut. 2022 Mar;71(3):580-592. doi: 10.1136/gutjnl-2020-321663 . Epub 2021 Mar 11. PMID: 33707230 ; PMCID: PMC8862089.