Gastric submucosal tumors (SMTs) can arise from various tissues of the gastric wall. Of these tumors, gastrointestinal stromal tumors (GISTs) account for 65-80%, which have a malignant nature and require treatment. The advantage of using endoscopic full-thickness resection (EFTR) for intraluminal growth-type GISTs is the ability to preserve organ function by minimizing damage to the gastric wall and extraluminal tissue without corporal incision. The oncological and technical feasibility of EFTR for small GISTs is considered to be high. Accordingly, in September, 2020, endoscopic local resection was approved as the advanced medical care for gastric SMTs that fulfil the following indication criteria: size 11-30 mm, connection to the muscularis propria in EUS, intraluminal growth type, no ulceration, and histologically evident or clinically suspicious (growing tendency, irregular margin, or parenchymal heterogeneity) GISTs. Further prospective studies are warranted to verify the outcomes.

Biliopancreatic endoscopic procedures are broadly classified into ERCP and EUS, both of which are indispensable in the current treatment of biliopancreatic diseases. Their education is extremely important to ensure a uniform level of care. The Advanced Endoscopic Trainees Program (AETP) has been used for education of cholangiopancreatic endoscopic procedures mainly in Europe and the United States, and the EUS and ERCP Skills Assessment Tool (TEESAT) has recently been proposed as an assessment method for the AETP; however, in Japan, the TEESAT is not yet available, and there is still no established evaluation or educational method. Many books and videos on related techniques have been published in recent years to assist in the education of biliopancreatic diseases. Live seminars, virtual simulators, and hands-on training using dry and wet models and actual living animal models have been actively developed and implemented. In Japan, it is important to make good use of these tools to learn biliopancreatic endoscopy-related procedures and explore related case studies under the supervision of senior physicians at their own institutions.

A 61-year-old man was regularly followed up as an outpatient after receiving treatment for alcoholic cirrhosis and esophageal varices. The patientʼs gastric mucosa was injured by the scope during follow-up EGD; however, the bleeding resolved spontaneously. On day 9 after the EGD, the patient experienced epigastralgia and developed a fever. CT performed the following day revealed diffuse thickening of the gastric wall, which was attributed to phlegmonous gastritis. The patient was administered ampicillin sodium/sulbactam sodium. Blood culture of a biopsy specimen obtained during EGD on day 5 of hospitalization revealed alpha-hemolytic streptococci, which were also detected in the culture of the blood sample drawn on admission. Post-EGD phlegmonous gastritis is rare; however, immunocompromised patients with comorbidities such as diabetes, liver cirrhosis, and cancer are predisposed to this condition.

A 69-year-old woman presented to our hospital for evaluation of abdominal pain and vomiting. CT revealed four air-containing gastric masses and one jejunal mass measuring up to 37 mm in size. The jejunal mass occupied the lumen, and the oral gastrointestinal tract was dilated and filled with intestinal fluid. Considering the patientʼs history of persimmon consumption, we suspected that the mass was a persimmon gastrolith, and the gastric stone had likely passed into the jejunum. We did not detect any evidence of peritoneal irritation; therefore, the patient received conservative treatment. We performed cola lysis therapy following ileus tube insertion and decompression. The gastrolith passed into the ileum and was eventually incarcerated in the ileum. We inserted a single balloon endoscope by the transanal route, injected cola and successfully used a snare to crush and remove the stone. Stone analysis revealed 98% tannin, which was consistent with the clinical suspicion of a persimmon gastrolith.

A 50-year-old woman with neurofibromatosis type 1 who hospitalized for chronic diarrhea was transferred to our hospital for evaluation of small intestinal dilatation and thickening. Transoral double-balloon enteroscopy revealed jejunal dilatation and suppressed peristalsis; however, mucosal inflammation, such as ulcers or erosions were not detected. Transanal double-balloon enteroscopy detected the intestinal stenosis with inflammatory polyps and a longitudinal ulcer. Histopathological evaluation of duodenal, jejunal, and ileal specimens by biopsy revealed ganglion cells and Schwannian cells; therefore, the patient was diagnosed with ganglioneuromatosis with neurofibromatosis type 1. Small intestinal dilatation was associated with suppressed peristalsis caused by ganglioneuromatosis and was diagnosed as secondary chronic intestinal pseudo-obstruction. Abdominal distention persisted despite conservative therapy. However, she remained asymptomatic, and oral intake remained unaffected. Ganglioneuromatosis is rare; however, clinicians should be mindful that ganglioneuromatosis is an abdominal complication associated with systemic disease such as neurofibromatosis type 1 and multiple endocrine neoplasia type 2B.

A 67-year-old man underwent CS for evaluation of positive results on fecal occult blood tests 7 years prior to presentation. CS revealed a cecal submucosal tumor, suspicion of hemangioma. At the current visit, we performed CS for detailed evaluation of other diseases. The submucosal tumor detected 7 years earlier was clearly increased. The patient was asymptomatic; however, surgery was performed to avoid the risk of future bleeding. Histopathological evaluation of the surgical specimen showed a cavernous hemangioma in a part of the resected lesions; however, most lesions were venous hemangiomas, which consisted of dilated veins accompanied by abundant elastic fibers and smooth muscle in the vascular media. A venous hemangioma can be considered a type of venous malformation; therefore, in recent years, the expression venous malformation is commonly used to refer to venous hemangiomas. Some studies have reported colonic hemangiomas; however, their incidence is low. Histopathologically, these lesions represent cavernous hemangiomas, which are discovered in patients with symptoms, such as rectal bleeding. We report a case of a histopathologically rare variant of growing cecal venous hemangioma in an asymptomatic patient.

Endoscopic full-thickness resection (EFTR) of the stomach has been performed as a minimally invasive treatment for gastric submucosal tumors (SMTs), including gastrointestinal stromal tumors. SMTs with an intraluminal growth type, ＜3cm in diameter, and no ulceration are good candidates for EFTR. Among them, SMTs located in the lesser curvature are the best indication for EFTR because the mesogastrium attaches widely to the gastric serosa in such a location. The mesogastrium works as a barrier to gas flowing out of the stomach after active perforation during EFTR. The mesogastrium can help stop or, at least minimize, the escape of gas from the stomach into the peritoneal cavity; therefore, it is possible to continue endoscopic procedures under a good visual field. “Traction” is known to be one of the key steps in EFTR. Traction methods widely used in standard ESD may be insufficient due to the weight of the tumor. Devices for strong and effective traction used by the authorsʼ for EFTR are presented in this article. Additionally, perioperative management, actual procedures, and some trouble-shooting tips for EFTR are discussed.

The importance of endoscopic resection for duodenal tumors is increasingly being recognized; however, the high frequency of complications, such as bleeding and perforation, during EMR has become a problem.

In recent years, an increasing number of studies have demonstrated the clinical usefulness of underwater EMR, in which the intestinal lumen is filled with water, and lesions are resected by snaring without injection. This technique has been shown to have a higher en bloc resection rate and a shorter procedure time than conventional EMR. However, some areas are difficult to fill with water, and bile and mucus slime in water can reduce visibility. Therefore, the use of gel immersion EMR (also called undergel EMR), in which lesions are immersed in a gel for endoscopic hemostasis instead of in water, has occasionally been reported. This paper describes the methods and prospects of gel immersion EMR.

Objectives: Three subcategories of high-risk flat and depressed lesions (FDLs), laterally spreading tumors non-granular type (LST-NG), depressed lesions, and large sessile serrated lesions (SSLs), are highly attributable to post-colonoscopy colorectal cancer (CRC). Efficient and organized educational programs on detecting high-risk FDLs are lacking. We aimed to explore whether a web-based educational intervention with training on FIND clues (fold deformation, intensive stool/mucus attachment, no vessel visibility, and demarcated reddish area) may improve the ability to detect high-risk FDLs.

Methods: This was an international web-based randomized control trial that enrolled non-expert endoscopists in 13 Asian countries. The participants were randomized into either education or non-education group. All participants took the pre-test and post-test to read 60 endoscopic images (40 high-risk FDLs, five polypoid, 15 no lesions) and answered whether there was a lesion. Only the education group received a self-education program (video and training questions and answers) between the tests. The primary outcome was a detection rate of high-risk FDLs.

Results: In total, 284 participants were randomized. After excluding non-responders, the final data analyses were based on 139 participants in the education group and 130 in the non-education group. The detection rate of high-risk FDLs in the education group significantly improved by 14.7% (66.6-81.3%) compared with -0.8% (70.8-70.0%) in the non-education group. Similarly, the detection rate of LST-NG, depressed lesions, and large SSLs significantly increased only in the education group by 12.7%, 12.0%, and 21.6%, respectively.

Conclusion: Short self-education focusing on detecting high-risk FDLs was effective for Asian non-expert endoscopists. (UMIN000042348).