Alessandro Antonello

Flexible endoscopic treatment for Zenker's diverticulum with the SB Knife. Preliminary results from a single-center experience

Flexible endoscopic septum division is becoming a prominent treatment option for Zenkers diverticulum (ZD). Over the years, various techniques have been developed and many cutting tools have been tested with varying results. We report our experience with a recently designed, monopolar, rotating, scissor‐shaped device (SB Knife).

Insulin promotes HER2 signaling activation during Barrett’s Esophagus carcinogenesis

BACKGROUND Insulin-resistance and hyperinsulinemia could have a role in the growing incidence of esophageal adenocarcinoma (EAC) and its pre-cancerous lesion Barretts Esophagus (BE). HER2 activation has also a pivotal role in EAC carcinogenesis but no data correlate these two phenomena in this disease context. AIMS To investigate the role of hyperinsulinemia in BE-dysplasia-adenocarcinoma sequence and the possible relationship between insulin-mediated and HER2 signaling in EAC development. METHODS Serum insulin, C-peptide, IGF1, glucagon, IL-6, TNF-alpha, leptin, adiponectin and Insulin-Resistance-index were analyzed in 19 patients with gastro-esophageal reflux disease, 51 with BE, 24 with dysplastic-BE and 14 with EAC. Insulin/IGF1/HER2 pathways were analyzed in esophageal biopsies using Luminex® Technology. Insulin effect was also evaluated in EAC-derived OE19 cells. Data were analyzed by Fishers exact test, Kruskal-Wallis test, Mann-Whitney U-test, Cuzicks test and Spearman correlation coefficient calculation. RESULTS Insulin-Resistance-index, insulin and C-peptide levels increased along with disease progression (p=0.019, p=0.002, p<0.0001, respectively) and correlated with HER2 expression and with downstream mediators phospho-Akt and phospho-mTOR in esophageal tissue. In vitro, insulin was also able to induce cell proliferation through HER2 activation. CONCLUSIONS Our data pinpoint a possible role of hyperinsulinemia in the Barretts Esophagus metaplasia-dysplasia-adenocarcinoma sequence through HER2 activation in esophageal epithelial cells.

Double incision and snare resection in symptomatic Zenker’s diverticulum: a modification of the stag-beetle knife technique

We read with great interest the article entitled “Double incision and snare resection in symptomatic Zenker’s diverticulum: a modification of the stag beetle knife technique” by Gölder et al. [1]. Although not acknowledged or cited, this appears to be an adaptation of the double-incision and snare technique first described by our group [2]. This is what we described: two parallel incisions were made to dissect the mucosa and the horizontal fibers of the cricopharyngeal muscle using the SB Knife (Sumitomo Bakelite Ltd., Tokyo, Japan); a monopolar snare was used to remove the portion of the septum in between. Endocut currents were used throughout the procedure (VIO 200D; ERBE Electromedizin, Tübingen, Germany). The depth of the incision was variable from patient to patient, dependent on the size of the diverticulum, and was balanced to achieve a near-complete cricopharyngeal myotomy but without the risk of perforation. Two or three clips (Clip HX-610-090L; Olympus, Tokyo, Japan) were deployed at the site of the incision to prevent mucosal dissection and perforation (▶Fig. 1). There was no further dissection of the cricopharyngeal muscle, as this had already been resected with the snare. What Gölder et al. describe is a suboptimal version of our technique in which two parallel incisions are carried out and the mucosa between the incisions and some of the muscle fibers are snared; dissection of the cricopharyngeal muscle is then performed afterward [1]. This is no different to the single-incision technique, which is commonly used, as it does not physically remove the septal wall to improve the emptying of the diverticular pouch, as is described in our technique.