Helicobacter pylori (H. pylori) infection is a major pathogen of gastric cancer, and many cohort studies, randomized controlled trials, and meta-analyses have shown that eradication therapy suppresses gastric cancer development. However, gastric cancer is not completely suppressed even after eradication, and post-eradication gastric cancer remains a problem. The risk factors for post-eradication gastric cancer include male sex, advanced age, high degree of atrophy and intestinal metaplasia, and the appearance of map-like erythema, which is difficult to identify due to the epithelium with low grade atypia and endoscopic gastritis-like findings on the surface. Most post-eradication gastric cancers are of the differentiated type, but undifferentiated gastric cancers are often advanced; thus, careful endoscopic surveillance is required. Ten years after eradication, the incidence of undifferentiated gastric cancer increases in patients with mild to moderate atrophy, and lack of follow-up after eradication is a risk factor of undifferentiated gastric cancer. Recent studies have shown that careful endoscopic follow-up with specific and magnifying endoscopy more than 10 years after eradication, the degree of abnormal gastric mucosal DNA methylation, the Kyoto Classification of Gastritis, and the other indicators may be useful for the early detection and treatment of gastric cancer after H. pylori eradication.

There are two types of peroral cholangioscopy (POCS); mother-baby peroral cholangioscopy (MB-POCS) and peroral direct cholangioscopy (PDCS). Although PDCS uses a thin endoscope, such as a nasal endoscope, its indication is limited due to technical problems. In Japan, the CHF-B290, with its superior image quality, and SpyGlass^TMDS, with its superior maneuverability and irrigation efficacy for bile and debris, are widely used as the baby scope of MB-POCS. POCS diagnosis is useful to differentiate benign and malignant biliary strictures and evaluate superficial intraductal spread of bile duct cancer. POCS treatment is useful in removing difficult biliary stones. However, the performance and types of devices for POCS diagnosis and treatment are limited. Further improvement of current devices and creation of new devices are needed to further advance POCS scopes. New advancements in POCS, such as image-enhanced endoscopy and artificial intelligence (AI) diagnostics, are emerging, and further developments are expected eventually.

Background/Aims: The prevalence of common bile duct stones is known to increase with age, as evident in the number of older adults >90 years who have this condition. Although several studies on endoscopic treatment for common bile duct stones in older adults have been reported, few studies have examined patients aged >90 years.

We aimed to evaluate the efficacy and safety of endoscopic therapy for patients in the said age group.

Methods: We retrospectively collected data of 86 patients (>90 years old) who have attempted endoscopic treatment at two institutions—Toyama Red Cross Hospital and Itoigawa General Hospital—between April 2015 and March 2022. We compared the efficacy and safety of endoscopic stone removal with those of permanent biliary stenting by assessing the incidence of adverse events (AEs) and rate of cholangitis recurrence.

Results: Of the 86 patients, 56 had undergone complete endoscopic stone removal and 30 had undergone permanent biliary stenting. Three (5.3%) patients in the stone removal group and one (3.3%) patient in the biliary stenting group experienced early AEs, with no significant differences between the groups. Recurrent cholangitis happened more frequently in the biliary stenting group (43.3%) than in the endoscopic stone removal group (10.7%; P = 0.001). Two patients died of cholangitis.

Conclusions: In older adults >90 years who can be treated endoscopic therapy, it is better to attempt complete endoscopic stone removal for bile duct stone treatment, instead of just biliary stenting.

A 72-year-old male complained of epigastric pain and heartburn one year after beginning to use dabigatran. Upper gastrointestinal endoscopy revealed exfoliative esophagitis with white membrane-like deposits in the middle and lower esophagus. We diagnosed the patient with dabigatran-induced esophagitis (DIE). Two months after discontinuation of dabigatran, upper gastrointestinal endoscopy revealed that the esophagitis had resolved, revealing advanced esophageal cancer of three-quarter circumference in the lower esophagus. This observation suggests that DIE was induced by dabigatran retention due to esophageal cancer.

Few case reports associate DIE with esophageal cancer. We thus consider this case to provide a valuable insight into the mechanism of DIE, and report it here along with a literature review. In case of DIE, it is important to perform endoscopic examination with attention to esophageal cancer and other findings that may cause obstruction.

While undergoing colonoscopy for hematochezia, a 47-year-old female was found to have an ulcerous lesion associated with a submucosal tumor (SMT), in the sigmoid colon. It was diagnosed as a poorly differentiated adenocarcinoma by H&E staining. CT and MRI showed intrapelvic tumors, in addition to the sigmoid colon tumor. The tumor marker CA 125 was high. The sigmoid colon tumor was CK7(+), CK20(-), and Pax-8(+) by immunostaining and it was diagnosed as a metastatic tumor of gynecologic carcinoma. Diagnostic laparoscopy revealed disseminated nodules in the mesentery and pelvic floor, but there were no abnormalities in the ovaries, and the patient was diagnosed with primary peritoneal carcinoma. Debulking surgery was successfully performed after 3 courses neoadjuvant chemotherapy of carboplatin and paclitaxel. The final diagnosis was ovarian carcinoma because a similar histological pattern was also observed in the ovarian parenchyma. There are few reports of synchronous colorectal metastasis from ovarian carcinoma. Immunostaining is important for differential diagnosis of malignant colorectal tumors with intrapelvic tumors.

PureStat^Ⓡ, a self-assembling peptide solution, has been approved and marketed in Japan as a hemostatic agent for gastrointestinal endoscopy. We report a case of a 60-year-old man who was successfully treated for bleeding with PureStat^Ⓡ after colorectal EMR, in which the bleeding point was difficult to identify. He was referred to our hospital after a colonoscopy at his previous hospital revealed an elevated lesion in the sigmoid colon. After EMR for a 15-mm type-Ⅰsp colorectal tumor in the sigmoid colon, there was pulsatile bleeding from the wound. The wound was sutured with multiple clips, but the bleeding persisted through the gap between the clips. Because a series of clips were already attached to the wound, additional clips could not be applied. In addition, coagulation and hemostasis with hemostatic forceps were difficult due to the inability to identify the bleeding point. Therefore, hemostasis was performed using PureStat^Ⓡ. This case suggests that the application of PureStat^Ⓡ may be a safer treatment option for post-EMR hemorrhage patients whose bleeding cannot be controlled by clipping alone.

A 66-year-old man visited our hospital due to pancreatic duct dilatation. Magnetic resonance cholangiopancreatography showed dilatation of the main pancreatic duct. ERCP showed the absence of a connection with the main pancreatic duct on ventral pancreatography from the main papilla. Dorsal pancreatography from the accessory papilla showed localized stenosis of the accessory duct at the pancreatic head and main pancreatic duct dilation. Moreover, EUS showed an 11-mm hypoechoic mass in the region of the accessory pancreatic duct. The mass was hypovascular in the early phase of Sonazoid contrast. As pancreatic head cancer complicated by pancreatic divisum was suspected, subtotal stomach-preserving pancreaticoduodenectomy was performed. The pathological diagnosis was pancreatic cancer in the region of the accessory pancreatic duct. In this case, pancreatic cancer could be diagnosed at an early stage because the pancreatic duct dilatation occurred at an early stage. This was due to decreased pancreatic juice drainage from the main pancreatic duct caused by the pancreas divisum.

Recently, the incidence of colonic diverticular bleeding (CDB) has been increasing due to aging and extensive use of non-steroidal anti-inflammatory drugs and antithrombotic drugs. While the clipping method is conventionally applied for endoscopic hemostasis of CDB, ligation method is also widely used clinically. The ligation method includes two techniques; endoscopic band ligation (EBL) using a rubber band and endoscopic detachable snare ligation (EDSL) using an endoloop. This method enables suction and inversion of a diverticular dome into an endoscopic attachment cap and ligation of the diverticular neck. In the ligation method, the risk of rebleeding was reported to be significantly lower compared with the conventional clipping method. Here, we review and discuss the EBL and EDSL techniques for CDB.

A concern of using metal stents to address biliary drainage is stent dysfunction induced by duodenal reflux; therefore, anti-reflux metal stent (ARMS) with anti-reflux valve (ARV) have been developed to solve this problem. Although various ARMS have been reported till date, the superiority over conventional metal stents have not been fully demonstrated. Therefore, further development for ARMS is indispensable. Biliary stenting using an ARMS is almost similar to that using the conventional metal stent; however, the metal part of the ARMS should be placed across the papilla to ensure the exposure of ARV in the duodenum. An ARMS needs to be exchanged when stent dysfunction occurs, as with the conventional metal stent. For cases with difficulties in ARMS extraction, additional stent placement utilizing a stent-in-stent technique or other biliary interventions, such as percutaneous drainage or transluminal drainage using endoscopic ultrasound, should be considered.

Objectives: Balloon enteroscopy (BE)-assisted endoscopic retrograde cholangiopancreatography (ERCP)-related procedures to resolve acute cholangitis (AC) in patients with surgically altered anatomy (SAA) are limited. There is a lack of evidence on whether the timing of BE-assisted ERCP affects clinical outcomes in patients with AC. This study aimed to evaluate the clinical outcomes of short-type single-balloon enteroscopy (short SBE)- assisted ERCP in patients with SAA and AC.

Methods: Patients with AC who underwent short SBE-assisted ERCP procedures between September 2011 and April 2022 were retrospectively reviewed. The outcomes of procedures undergone at ≤24 h and >24 h were compared. The primary outcome was the length of stay (LOS).

Results: Overall, 56 patients underwent procedures at ≤24 h, and 58 patients at >24 h. The procedural success and adverse event rates of short SBE-assisted ERCP were 87.7% (95% confidence interval [CI] 80.3-93.1%) and 4.4% (95% CI 1.4- 9.9%), respectively. Patients with severe (Grade Ⅲ) AC and systemic inflammatory response syndrome were more in early (at ≤24 h) ERCP groups. LOS and median time from ERCP procedures to discharge were shorter in the early group. Procedural success and adverse event rates between both groups had no significant differences. Multivariable linear regression analysis showed that ERCP performed at ≤24 h was associated with shorter LOS, while severe cholangitis and malignant biliary obstruction were associated with longer LOS.

Conclusions: Short SBE-assisted ERCP is effective and safe in patients with SAA and AC. Early procedures seemed to attribute early improvement of general condition, thus shortening the LOS.