Gastric Fundus Research Articles

378. GASTRIC FILLING IN NEOADJUVANT CHEMORADIOTHERAPY FOR OESOPHAGEAL CANCER

Abstract Background Neoadjuvant Chemoradiotherapy (nCRT) for locally advanced oesophageal cancer improves survival. Currently, there is equipoise in the survival benefit of nCRT versus neoadjuvant chemotherapy. Excessive radiotherapy to the gastric conduit prior to surgery has long been a concern. Recent studies have linked radiation doses to the gastric fundus around 30 Gy to an increased risk of anastomotic leak. This study reviews a simple process aiming to reduce radiation dose to the gastric fundus. Methods This is a single-centre, retrospective analysis of 63 adult patients treated with nCRT (CROSS protocol) then oesophagectomy with a gastric conduit reconstruction. The Gastric Fill (GF) arm were given 500 mL of water prior to radiotherapy planning and treatment. The control group were consecutive patients prior to the implementation of the GF protocol. The fundus was mapped on radiotherapy software and planned to treat it like other organs at risk. Radiation dose to the fundus was recorded and compared between the two groups. Results The GF arm included 25 patients, with 38 patients in the control arm. Patients drank 350–800 mL of water prior to planning and treatment. There were no reported aspiration events. Radiotherapy techniques included VMAT and 3DCRT. All GF patients were treated with VMAT. There was a higher proportion of mid-oesophageal tumours in the control group (21% compared with 4%). The mean volume of gastric fundus in the GF group (mean = 215 cc, SD 144) was higher than the control group (mean = 155 cc, SD 100). The proportion of gastric fundus receiving >30 Gy was lower in the GF group (mean = 10.9% SD = 16.0) compared with the control group (mean = 19.1% SD = 24.8). Conclusion Analysis did not show statistically significant difference between the groups, however, there was a trend suggesting radiation to the gastric fundus was reduced in the GF group. This study shows the feasibility of a simple and low risk intervention in reducing the radiation to the future gastric conduit. Further review with a larger cohort, and impact on anastomotic complications would be of interest for future review.

Inadequate gastric preparation and its associated factors for magnetically controlled capsule endoscopy.

Goals: To explore factors associated with inadequate gastric preparation for MCE. Background: Factors associated with inadequate gastric preparation for magnetically controlled capsule endoscopy (MCE) remains unclear. Study: Data of patients who underwent MCE from June 2021 to July 2022 were prospectively collected. The gastric cleanliness score (GCS) of the six stomach regions (gastric cardia, fundus, body, angulus, antrum, and pylorus) was recorded. Patients with GCS score ≥18 were defined as the adequate preparation. Factors related to inadequate gastric preparation were analyzed using a logistic regression model with estimated odds ratios (OR). Results: The mean GCS score of 211 patients was 17.01 ± 2.82. In the multivariable analysis, proton pump inhibitor (PPI) use (OR 3.57; 95% CI 1.69-7.95; p < 0.01) and premedication time after administering simethicone <30min (OR 2.86; 95% CI 1.10-7.39; p = 0.03) were independent risk factors for inadequate gastric preparation. Comparing the gastric cleanliness of different locations, the median GCS of the lower stomach [10.00, IQR (9.50, 11.00)] was significantly higher than that of the upper stomach [7.00, IQR (6.00, 8.00)] (p <0.001). Conclusion: PPI use and inadequate premedication time (<30min) may reduce the quality of gastric preparation for MCE. The type, dose, duration of medication, and discontinuation time of PPIs was well worth further exploration. Appropriate control of the type and time of premedication may be the key to improving overall gastric cleanliness.

The effect of endoscopic ultrasound on the precise selection of endoscopic treatment for submucosal tumors in the upper gastrointestinal tract

ObjectiveTo summarize and discuss the guiding role of endoscopic ultrasound (EUS) in selecting endoscopic treatments for submucosal tumors (SMTs) in the upper gastrointestinal tract.MethodsA retrospective investigation was conducted on 156 SMT patients who received endoscopic resection guided by EUS in the endoscopy center of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine from May 2019 to September 2021. Next, the size, pathological type, and distribution of lesions were analyzed; the correlation of the tumor origin with distribution of lesions and selection of treatments was explored; and the consistency of preoperative EUS diagnosis and postoperative pathological diagnosis was summarized and analyzed.ResultsThe tumor diameters of the included SMT patients ranged from 0.3 to 4 cm, with a mean diameter of 0.95 cm; the lesions were mostly located in the esophagus, gastric fundus or fundic cardia and gastric body. As for the pathological types, liomyoma was the most common tumor in the esophagus, liomyoma and mesenchymoma were mainly located in the fundic cardia and gastric body, and heterotopic pancreas was mostly discovered in the gastric sinus. Among 38 esophageal SMT patients, some with lesions originating from muscularis mucosa and submucosa under EUS mainly underwent endoscopic submucosal dissection (ESD) and endoscope band ligation (EBL); while others with lesions originated from muscularis propria mainly received submucosal tunneling endoscopic resection (STER). Of 115 gastric SMT patients under EUS, some with lesion origins from the muscularis mucosa and submucosa mainly underwent endoscopic submucosal excavation (ESE), while others from muscularis propria mainly underwent ESE, ESD, and endoscopic full-thickness resection (EFTR). Besides, 3 duodenal SMT patients with lesion origins from submucosa and muscularis propria under EUS were given ESD and ESE, respectively. Additionally, 121 cases showed a consistency between the EUS diagnosis and the postoperative pathological nature, and the consistency rate was 84.6%.ConclusionClarifying the origin layer, size, growth pattern, and pathological nature of the lesion through preoperative EUS can guide the precise selection of endoscopic treatments, thereby ensuring a safe, effective, and complete surgical outcomes and reducing complications.

Adiponectin Modulates Smooth Muscle Cell Morpho-Functional Properties in Murine Gastric Fundus via Sphingosine Kinase 2 Activation.

Adipokines are peptide hormones produced by the adipose tissue involved in several biological functions. Among adipokines, adiponectin (ADPN) has antidiabetic and anti-inflammatory properties. It can also modulate food intake at central and peripheral levels, acting on hypothalamus and facilitating gastric relaxation. ADPN exerts its action interacting with two distinct membrane receptors and triggering some well-defined signaling cascades. The ceramidase activity of ADPN receptor has been reported in many tissues: it converts ceramide into sphingosine. In turn, sphingosine kinase (SK) phosphorylates it into sphingosine-1 phosphate (S1P), a crucial mediator of many cellular processes including contractility. Using a multidisciplinary approach that combined biochemical, electrophysiological and morphological investigations, we explored for the first time the possible role of S1P metabolism in mediating ADPN effects on the murine gastric fundus muscle layer. By using a specific pharmacological inhibitor of SK2, we showed that ADPN affects smooth muscle cell membrane properties and contractile machinery via SK2 activation in gastric fundus, adding a piece of knowledge to the action mechanisms of this hormone. These findings help to identify ADPN and its receptors as new therapeutic targets or as possible prognostic markers for diseases with altered energy balance and for pathologies with fat mass content alterations.

Topflight endoscopic submucosal dissection: a novel strategy for the resection of gastric fundus tumors

Video 1Resection of a gastric lesion using Topflight ESD.

Systemic Lupus Erythematosus in a Patient with Liver Cirrhosis: Case Report and Literature Review

Background: There are no treatment guidelines for systemic lupus erythematosus (SLE) for the patients with decompensated cirrhosis, especially for those who have a history of hepatitis B virus (HBV) infection, gastrointestinal bleeding and gastric fundus ulceration. Case Presentation: A 50-year-old woman who had a six-year history of lupus was admitted to our hospital. One month prior, at the Department of Gastroenterology, she was diagnosed with decompensated liver cirrhosis with gastric fundal varicose bleeding, and HBV-related infection. During her visit to the hospital, gastroscopy showed esophageal varices and a large gastric fundus ulcer. Laboratory data indicated the rapid decrease of red blood cells, granulocytes and platelets and the persistent increase of serum globulin levels. According to the patient's medical history and existing laboratory examination, the patient experienced an exacerbation of SLE, which could be life-threatening.-While it remained uncertain whether the liver cirrhosis was caused by SLE or the HBV infection, immediate treatment was necessary. Consequently, she was treated with a low dose of methylprednisolone and mycophenolate mofetil (MMF). The treatment resulted in significant clinical improvement. Moreover, there was no indication of HBV reactivation, gastrointestinal bleeding, liver dysfunction or other drug-induced side effects. Conclusion: This case indicated that irrespective of the underlying causes of liver cirrhosis, the combination of a low dose of methylprednisolone and MMF is an effective treatment method to inhibit the disease process for patients with SLE and decompensated liver cirrhosis, a large gastric fundus ulcer and HBV infection.

Management and outcomes of gastric leak after sleeve gastrectomy: results from the 2010-2020 national registry.

Management of gastric leak after sleeve gastrectomy (SG) is challenging due to its unpredictable outcomes. We aimed to summarize the characteristics of SG leaks and analyze interventions and corresponding outcomes in a real-world setting. To retrospectively review of 15,721 SG procedures from 2010 to 2020 based on a national registry. A cumulative sum analysis was used to identify a fitting curve of gastric leak rate. The Kaplan-Meier method and log-rank tests were performed to calculate and compare the probabilities of relevant outcomes. The logistic regression analysis was conducted to determine the predictors of acute leaks. A total of 78 cases of SG leaks were collected with an incidence of 0.5% (78/15,721) from this registry (6 patients who had the primary SG in non-participating centers). After accumulating 260 cases in a bariatric surgery center, the leak rate decreased to a stably low value of under 1.17%. The significant differences presented in sex, waist circumference, and the proportion of hypoproteinemia and type 2 diabetes at baseline between patients with SG leak and the whole registry population ( P = 0.005, = 0.026, <0.001, and = 0.001, respectively). Moreover, 83.1% (59/71) of the leakage was near the esophagogastric junction region. Leakage healed in 64 (88.9%, 64/72) patients. The median healing time of acute and non-acute leaks was 5.93 months and 8.12 months, respectively. Acute leak (38/72, 52.8%) was the predominant type with a cumulative reoperation rate >50%, whereas the cumulative healing probability in the patients who required surgical treatment was significantly lower than those requring non-surgical treatment ( P = 0.013). Precise dissection in the His angle area was independently associated with a lower acute leak rate, whereas preservation ≥2 cm distance from the His angle area was an independent risk factor. Male sex, elevated waist circumference, hypoproteinaemia, and type 2 diabetes are risk factors of gastric leaks after SG. Optimizing surgical techniques, including precise dissection of His angle area and preservation of smaller gastric fundus, should be suggested to prevent acute leaks.

Robotic Function-Preserving Resection of Gastric Gastrointestinal Stromal Tumor

IntroductionGastric gastrointestinal stromal tumors (GISTs) located at the gastroesophageal junction (GEJ), lesser curvature, posterior gastric wall, or antrum present challenges for gastric function preservation. The aim of this study was to evaluate safety and effectiveness of robot-assisted resection of gastric GIST in challenging anatomic locations. MethodsThis was a single-center case series of robotic gastric GIST resections in challenging anatomic locations performed from 2019 to 2021. GEJ GISTs are defined as tumors within 5 cm of the GEJ. Location of the tumor and distance from the GEJ were determined from the endoscopy report and/or cross-sectional imaging and operative findings. ResultsThere were 25 consecutive patients who underwent a robot-assisted partial gastrectomy for a gastric GIST in challenging anatomic locations. Tumors were located at the GEJ (n = 12), lesser curvature (n = 7), posterior gastric wall (n = 4), fundus (n = 3), greater curvature (n = 3), and antrum (n = 2). Median distance of tumor from GEJ was 2.5 cm. Both GEJ and pylorus were successfully preserved in all patients regardless of tumor location. Median operative time was 190 min with a median estimated blood loss of 20 mL and no conversion to open approach. Median hospital stay was 3 d with solid diet intake starting 2 d after surgery. Two (8 %) patients had Grade III or higher postoperative complications. Median tumor size upon resection was 3.9 cm. Negative margins were obtained in 96.3%. There was no evidence of recurrent disease with a median follow-up of 11.3 mo. ConclusionsWe demonstrate the safety and feasibility of using the robotic approach to facilitate function preservation gastrectomy in challenging anatomic locations without compromising oncologic resection.

A255 Case Report: Hiatal Hernia with Gastric Fundus Herniation and Obstruction After Sleeve Gastrectomy

A255 Case Report: Hiatal Hernia with Gastric Fundus Herniation and Obstruction After Sleeve Gastrectomy

Clinical and pathological characteristics of gastric adenocarcinoma of fundic gland type

To analyze the clinical, endoscopic and pathological feature of gastric adenocarcinoma of fundic gland type (GA-FG) (18 cases) collected from Sir Run Run Shaw Hospital, affiliated with Zhejiang University School of Medicine and Taizhou Hospital of Zhejiang Province from January 2019 to July 2022. There were 18 cases of patient of GA-FG, including male 12 cases, female 6 cases, aged from 38 to 78 years old, with average age of 60.5 years old. Gastroscopy showed that bulging or flat lesions of gastric fundus were 0.2-5.5 cm in size, and the mucosal surface was smooth, redness or rough. Histologic examination showed that tumor cells were dominated by chief cells and scattered with a few oxyntic cells, formed a complex gland that anastomoses each other, and infiltrated to the submucosa. The results of immunohistochemistry showed that tumor cells were positive for the expression of mucin-6 (MUC6) and Pepsinogen 1, and partial expression of synaptophysin (Syn). GA-FG is a rare type of gastric adenocarcinoma with good differentiation, and currently only a few cases have been reported, and often easily been misdiagnosed or missed. Therefore, to master the characteristics of clinic and pathology is helpful to improve the ability of clinical pathologists in differential diagnosis.

Bariatric endoscopic antral myotomy: first-in-human proof of concept of a novel therapeutic method to delay gastric emptying and induce weight loss

Bariatric endoscopic antral myotomy: first-in-human proof of concept of a novel therapeutic method to delay gastric emptying and induce weight loss

A novel technique for endoscope progression in gastroscopy resection: forward-return way for dissection of stromal tumor in the muscularis propria of the gastric fundus.

The fundus of the stomach is a challenging region for endoscopic resection of gastrointestinal stromal tumors (GISTs), especially in the anterior wall of the fornix at the side of the greater curvature. This study aimed to introduce the Forward-Return Way (FRW) technique in gastric fundus operations and provide evidence of its advantages. The FRW technique allows the gastroscope to access the stomach fornix without entering the gastric antrum after passing through the gastric cardia. Using FRW, the gastroscope body makes a forward return along the wall of the posterior wall of the upper gastric body and the wall of the greater curvature. The clinical data of patients with stromal tumors in muscularis propria at the gastric fundus (STMF) at the Fourth Hospital of China Medical University between May 2020- March 2021 were reviewed. The novel FRW technique was used in the procedures, and the beneficial effects, suitability, applicable lesion site, and success rates of FRW were analyzed. A total of 10 cases were reviewed, and the FRW technique was successfully performed in 7 cases (70%). The gastroscope's tip reached the area just below the gastric cardia, allowing endoscopists to successfully access all angles and sites of the stomach's fundus in all seven patients. The lesion was easily accessed, and the gastroscope was stable with good left-right and forward-backwards movements. The FRW technique significantly facilitates the resection of the GISTs by aligning the endoscopy body movement direction with the observation direction. Gastrointestinal Stromal Tumor; forward-return of gastroscopy along the gastric body wall; muscularis propria; gastric fundus.

P270 THE IMPORTANCE OF INTEGRATED IMAGING IN THE DIFFICULT DIFFERENTIAL DIAGNOSIS OF A LEFT INTRACARDIAC MASS IN YOUNG ADULT

Abstract The patient is a 34–year–old man who comes to the emergency room with mild hemoptysis, asthenia, low–grade fever, night sweats and weight loss. Cardiac auscultation reveals a diastolic murmur at the cardiac apex. Transthoracic and transesophageal echocardiograms are performed and show an isoechoic thickening encompassing the posterior leaflet, cranially involving the atrial septum and the lateral wall up to the inlet of the left atrial appendage and inferiorly involveing the subvalvular apparatus with diffuse thickening and chordal fusion. Functionally it determines a moderate mitral stenosis with an average gradient of 10 mmHg and a valve area of ​​1.1 cm2 and a mild–moderate regurgitation with an anteriorly directed eccentric jet. At this point we needed to make the differential diagnosis considering as possible etiologies infective endocardic vegetation, thrombosis, primary and secondary neoplasms, aseptic vegetation and inflammatory or rheumatic valvulitis. We therefore begin our diagnostic work–up by performing a scintigraphy with labeled leukocytes, which does not show the presence of hyperuptake areas referable to infective endocarditis, and a PET scan which shows, in addition to the increased uptake at the cardiac level, an area of ​​greater concentration of the metabolic tracer in the gastric area (between the body and the fundus). Given the confirmation of metabolically active tissue, the patient performed cardiac magnetic resonance with contrast medium which confirmed the presence of pathological tissue with inhomogeneous late post–contrast enhancement. After collegial discussion, due to the high risk of biopsy of the mitral lesion, which was poorly separable from the cardiac structures, given the other localization of the disease at the gastric level, it was decided to perform an EGDS with relief of an ulcerated lesion on the gastric fundus which is subjected to biopsy and histological typing. We then arrive at the diagnosis of “undifferentiated pleomorphic sarcoma”. Sarcoma is the most frequent histological type of primary malignant cardiac tumors. The clinic is characterized by constitutional symptoms, obstruction of the valve inflow or outflow tract, thromboembolism, and arrhythmias. It has a poor prognosis: 6–12 months from diagnosis. In conclusion, we reiterate the importance of integrated imaging to arrive at the final diagnosis, each method with a specific objective.

Synchronous gastric MALT lymphoma and gastric adenocarcinoma of fundic gland type arising from a hamartomatous inverted polyp in a Helicobacter pylori naive patient.

We present a rare case that showed the coexistence of gastric cancer and mucosa-associated lymphoid tissue (MALT) lymphoma in Helicobacter pylori-naive stomach. A 72-year-old man was followed up after surgery for epithelial carcinoma of the glottis at the Department of Otolaryngology. He underwent an upper gastrointestinal endoscopy for an abnormal PET-CT accumulation, which revealed gastric adenocarcinoma of fundic gland type in the gastric fundus and MALT lymphoma in the upper gastric body. Hence, we performed an endoscopic submucosal dissection for gastric cancer and diagnosed gastric adenocarcinoma of fundic gland type derived from a hamartomatous-inverted polyp. Subsequently, Gastric MALT lymphoma was treated with radiation therapy because the API2-MALT1 gene was positive and the Helicobacter pylori infection was negative. A complete response was observed. Even in Hp-naive stomachs, cases such as the present case are complicated by special types of gastric cancer and MALT lymphoma, and endoscopic examination should be performed with these diseases in mind.

Risk factors of perforation in gastric stromal tumors during endoscopic resection: a retrospective case-control study.

Perforation is a common complication during endoscopic resection (ER) of gastric gastrointestinal stromal tumors (gGISTs) associated with secondary infections, sepsis, hospitalization time and cost. However, the risk factors of perforation remain controversial. This study aimed to investigate the risk factors for perforation during ER of gGISTs. This retrospective case-control study included consecutive patients with gGISTs who underwent ER between June 2009 and November 2021 at the Nanjing Drum Tower Hospital. Univariate and multivariate analyses were performed to investigate the risk factors for perforation. Sensitivity analyses with propensity scoring (PS) were performed to evaluate the stability of the independent effects. In total, 422 patients with gGISTs were included. The following factors were associated with perforation during ER: in the non-intraluminal growth patterns (all confounders adjusted odds ratio [aOR]: 5.39, 95% CI 2.99-9.72, P < 0.001), in the gastric fundus (aOR 2.25, 95% CI 1.40-3.60, P = 0.007), sized ≥ 2cm (aOR 1.70, 95% CI 1.04-2.77, P = 0.035), in the lesser curvature (aOR 0.12, 95% CI 0.05-0.27, P < 0.001), and in the gastric cardia (aOR 0.13, 95% CI 0.04-0.50, P = 0.003). The PS analysis confirmed the stable independent effects of these identified risk factors. ERs of gGISTs in non-intraluminal growth patterns, in the gastric fundus, and with larger tumor size were independent risk factors for perforation. While tumors in the lesser curvature or gastric cardia were independent protective factor for perforation.

Acquired Gastric Dieulafoy-Like Lesion due to Aberrant Blood Supply Diverted From the Left Phrenic Artery to an Enlarged Splenule

Dieulafoy lesion is an aberrant submucosal vessel that can erode into the overlying tissue leading to hemorrhage. It is a rare but important cause of gastrointestinal bleeding. We present a case of a patient who developed an acquired Dieulafoy lesion 39 years after splenectomy. Abdominal computed tomography showed an aberrant vessel from a branch of the left phrenic artery, coursing through the gastric fundus to supply a splenule. Angiography with embolization of the aberrant vessel resulted in no further bleeding.

Evaluation of the normal gastrointestinal tract in cats using dual-phase computed tomography.

In cats, although ultrasonography remains the preferred modality to evaluate the gastrointestinal tract, computed tomographic (CT) examination of the abdomen is commonly performed. However, a normal description of the gastrointestinal tract is lacking. This study describes the conspicuity and contrast enhancement pattern of the normal gastrointestinal tract in cats using dual-phase CT. Pre- and dual-phase postcontrast (early scan at 30 seconds and late scan mean at 84seconds) abdominal CT exams of 39 cats without history, clinical signs or diagnosis of gastrointestinal disease were reviewed. The gastrointestinal tract was examined for conspicuity and enhancement pattern using commercially available viewing software (Osirix, v.6.5.2), and diameters of 16 gastrointestinal segments were recorded and compared with published radiographic and ultrasonographic reference values. Of the 624 gastrointestinal segments, 530 (84.9%) were identified on precontrast studies and 545 (87.3%) segments on postcontrast studies. Of the gastrointestinal wall segments, 257 (41.2%) were identified on precontrast studies and 314 (50.3%) on postcontrast studies. Gastrointestinal segment diameters correlated well with published normal values, whereas wall thickness measurements usually were smaller compared with sonographic normal values. Early mucosal surface enhancement was frequently seen in the gastric cardia and fundus and ileocolic junction, and a mainly transmural wall enhancement in other gastrointestinal segments. Dual-phase CT allows for the identification of gastrointestinal tract segments and walls in cats. Contrast enhancement improves conspicuity and demonstrates wall layering in the cardia, fundus and ileocolic junction.

Transcatheter arterial chemoembolization with lipiodol for advanced gastric fundus and cardia cancer.

Wang, Shuaia; Yin, Meipana; Ma, Yaozhena; Li, Xiaobinga; Jin, Shuilingb; Liu, Taoc; Zhu, Minga; Liu, Chaoa; Wu, Ganga Author Information

Research on mechanisms of acupoint sensitization in gastric ulcer mice from perspective of dorsal root ganglion neuronal excitability

To investigate the relationship between acupoint sensitization on the body surface and neuronal intrinsic excitability of the medium- and small-size dorsal root ganglion (DRG) neurons from the perspective of ion channel kinetics in mice with gastric ulcer. Male C57BL/6J mice were randomly divided into control (n=32) and model groups (n=34). The gastric ulcer model was established by injection of 60% glacial acetic acid (0.2 mL/100 g) into the gastric wall muscle layer and submucosa near the pylorus in the minor curvature of the stomach. In contrast, the same dose of normal saline was injected in the same way in the control group. Six days after modeling, Evans blue (EB) solution was injected into the mouse's tail vein for observing the number and distribution of the exudation blue spots on the body surface. Histopathological changes of the gastric tissue were observed by H.E. staining. Then, whole-cell membrane currents and intrinsic excitability of medium- and small-size neurons in the spinal T9-T11 DRGs were measured by in vitro electrophysiology combining with biocytin-ABC method. In the control group, EB exudation blue spots were not obvious, while in the model group, the blue spots on the body surface were densely distributed in the area of spinal T9-T11 segments, the epigastric region, and the skin around "Zhongwan" (CV12) and "Huaroumen" (ST24) regions, and near the surgical incision region. Compared with the control group, the model group had a high level of eosinophilic infiltrates in the submucosa of gastric tissues, severe gastric fossa structure damage, gastric fundus gland dilation and other pathological manifestations. The number of exudation blue spots was proportional to the degree of inflammatory reaction in the stomach. In comparison with the control group, the spike discharges of type II of medium-size DRG neurons in T9-T11 segments were decreased, and the current of whole-cell membrane was increased, basic intensity was decreased (P<0.05), discharge frequency and discharge number were increased (P<0.01,P<0.000 1); while the discharges of type I small-size DRG neurons were decreased, those of type II neurons increased, the whole-cell membrane current was decreased, and discharge frequency and discharge number were decreased (P<0.01, P<0.000 1). Both the medium- and small-size DRG neurons from the spinal T9-T11 segments involve in gastric ulcer-induced acupoint sensitization via their different spike discharge activities. And intrinsic excitability of these DRG neurons can not only dynamically encode the plasticity of acupoint sensitization, but also can help us understand the neural mechanism of acupoint sensitization induced by visceral injury.

Management of Large Subcardial Diverticula in Sleeve Gastrectomy: Technical Tips

Gastric diverticula are uncommon anatomic abnormalities that are usually asymptomatic or found incidentally in upper gastrointestinal radiographs with contrast or endoscopy. Gastric diverticula usually arise from the wall of the gastric fundus. Their preoperative study or intraoperative finding is of great importance in patients with obesity who are scheduled for bariatric surgery. In bariatric surgery, and especially in sleeve gastrectomy, it is of utmost importance to know the exact location of the diverticulum in order to position the stapler correctly and to perform appropriate gastric resection including the diverticulum. Sleeve gastrectomy has gained popularity worldwide and currently accounts for the most performed bariatric procedure according to more recent international surveys. It is considered to be a technically easy procedure. Nonetheless, some steps of the procedure, such as gastric fundus mobilization and the gastric resection with the use of the stapler, may be challenging in patients with a high BMI and in the presence of abnormalities of the gastric wall. This can represent a risk for the occurrence of complications such as a gastric leak or bleeding. We propose some considerations about technical tips to adopt for safely performing sleeve gastrectomy in the presence of a subcardial diverticulum.