Bleeding from esophageal or gastric varices in patients with underlying liver cirrhosis can lead to worsening of liver function, necessitating appropriate treatment. Established endoscopic treatment options include variceal ligation and injection sclerotherapy for esophageal varices, as well as tissue-adhesive injection therapy for gastric varices. However, various innovations have been made to date. To perform safe and effective treatment, it is important to fully understand the patientʼs condition and portal hemodynamics and to devise a strategy considering the patientʼs QOL.

Small intestinal lesions in Crohnʼs disease can cause obstructions and are known to have a high surgery rate. Management of small intestinal lesions is essential in treating Crohnʼs disease. In clinical practice, balloon-assisted endoscopy can assist with diagnosing Crohnʼs disease, which presents with lesions in areas that are difficult to visualize with a conventional ileocolonoscopy, and facilitate evaluation and monitoring of therapeutic effects on small bowel lesions. In addition, balloon dilation for symptomatic small bowel stricture has been reported to have a high procedural success rate and favorable long-term efficacy in lesions that meet the indication criteria, such as the absence of ulcers. Compared to other methods of evaluating small lesions, it has high accuracy for detecting small intestinal lesions and is the only method that enables tissue biopsy and endoscopic treatment. On the other hand, it is invasive, and adverse events such as gastrointestinal perforation, bleeding, and pancreatitis have been reported. In clinical practice, future discussions are expected on case-dependent selection of an optimal modality among various available modalities for evaluation and management of Crohnʼs disease, including balloon-assisted endoscopy.

A 58-year-old woman complained of dysphagia and underwent endoscopic examination that revealed a 12 mm protrusion in the upper thoracic esophagus. Histopathological examination of the biopsy specimens taken from the lesion led to a diagnosis of granular cell tumor. EUS showed that the tumor is located in the laminar propria mucosa and extended into the submucosal layer. In addition, there were multiple widespread pitting lesions on the esophageal mucosa that was diagnosed as intramural esophageal pseudodiverticulosis based on its characteristic endoscopic and radiographic findings, with constricted lower esophagus and poor expansion. Due to concerns over the presence or development of esophageal submucosal fibrosis, resection of the granular cell tumor was performed by ESD instead of EMR. Total en-bloc resection was achieved safely despite fibrosis of the submucosal layer being observed during the procedure. Herein, we report this very rare case of esophageal granular cell tumor complicated with esophageal intramural pseudodiverticulosis successfully resected by ESD.

A 72-year-old man was referred to our department because a 7-mm hyperechoic region in the pancreatic body was noted on abdominal ultrasonography. The pancreatic tumor was not visible on contrast-enhanced CT. MRI showed it as a defect in the pancreatic duct, with a main pancreatic duct (MPD) diameter of 4 mm in the pancreatic body. EUS showed an 11 mm isoechoic papillary tumor in the MPD of the pancreatic body. Pancreatography revealed an intraductal tumor without mucus. Serial pancreatic juice aspiration cytologic examination revealed columnar epithelial cell-containing mucus. Based on these findings, the patient was preoperatively diagnosed with intraductal papillary mucinous adenoma (IPMA) of the MPD with mild dilation, and laparoscopic distal pancreatectomy was performed. Pathological examination showed a solid mass measuring 10 × 4 × 4 mm in the MPD and the diagnosis was gastric-type IPMA with low-grade dysplasia.

A 76-year-old woman presented at the emergency department with severe abdominal pain. Two years prior, she had been diagnosed with rectal cancer with multiple lung metastasis. Abdominal CT revealed the presence of an impacted calcified gallstone within the narrow segment of the rectal cancer. Initial attempts to remove the stone using a mechanical lithotripter were unsuccessful due to the stoneʼs exceptional hardness. Consequently, an innovative approach was employed, utilizing a Holmium-Yttrium Aluminum Garnet (Ho-YAG) laser to fragment the gallstone, followed by complete removal of the stone fragments with a retrieval net. In conclusion, endoscopic treatment including the lithotripsy with the Ho-YAG laser may be considered before a surgical intervention.

This case study involves a 64-year-old male patient with an elevated lesion characterized by irregular depression located on the anterior wall of the gastric angle. The background mucosa displayed of fundic gland without atrophy and no intestinal metaplasia. The lesion, characterized by irregular microvascular pattern and micro-surface patterns was diagnosed as a well-differentiated tubular adenocarcinoma. Subsequently, the patient underwent ESD. Pathological analysis confirmed the presence of well-differentiated tubular adenocarcinoma, particularly classified as intramucosal carcinoma. Immunohistochemical staining was negative for MUC5AC and MUC6, but positive for MUC2, CDX2, and CD10, indicating a small intestinal phenotype within the lesion. The patient tested negative for H. pylori in the histological examination and had no history of H. pylori eradication. Based on the results of these blood tests for H. pylori, together with the pepsinogen test and endoscopic findings, it was determined that the patient was not infected with H. pylori. Since there is no previous report of a case of well-differentiated tubular adenocarcinoma with small intestinal phenotype arising from H. pylori uninfected fundic gland mucosa, we report this case with a review of the literature.

With the increasing number of treatments available for ESD in gastric tumors, the effective management of associated complications has gained increasing importance. Among these complications, bleeding complications are frequent and potentially severe; thus, it is necessary to develop preventive measures. Notably, Hatta et al. developed the BEST-J score, a predictive model designed to anticipate post-ESD ulcer bleeding for early gastric cancer. This score incorporated ten factors (hemodialysis, aspirin, thienopyridine antiplatelets, cilostazol, warfarin, direct oral anticoagulant (DOAC), discontinuation of antithrombotic drugs, presence of multiple tumors, tumor diameter ≥30 mm, lower stomach) to assess bleeding risk, enabling risk stratification based on the total score. Despite the advances, the challenge of implementing individualized treatment for patients with high bleeding risk remains a concern. Future studies must focus on developing endoscopic treatment and addressing patients using anticoagulants, which poses the highest risk of bleeding among all the risk factors.

Hepaticojejunostomy anastomotic stricture (HJAS) is a complicated clinical condition that has historically been treated with percutaneous transhepatic biliary drainage or surgical repair. The presence of long reconstructed gastrointestinal tract added to the complexity of the endoscopic treatment. However, recent advancements utilize less-invasive endoscopic approaches to HJAS; ERCP using a balloon-assisted endoscope and endoscopic ultrasonography-guided intervention. Balloon dilation combined with plastic stent placement has become the standard of care, whereas temporary placement of a fully-covered metal stent is reported to be a promising new modality. In this review, technical aspects of the endoscopic procedures for HJAS are discussed along with the literature review.

Objectives: Endoscopic submucosal dissection (ESD) is a widely used treatment for early gastrointestinal cancer. However, colon ESD remains challenging. Previous studies on colon ESD using the traction method used a small sample, single-center design, providing insufficient evidence of this procedureʼs efficacy. We thus aimed to investigate the efficacy and safety of the traction method in colon ESD in this multicenter randomized trial.

Methods: We conducted a prospective, multicenter, randomized, two-arm controlled trial at 10 facilities in Japan. A 1:1 allocation was conducted for the conventional ESD (C-ESD) and traction ESD (T-ESD) groups. The primary end-point was ESD procedure time.

Results: We included 128 C-ESD and 123 T-ESD cases from April 2020 to August 2021. The median procedure times for C-ESD and T-ESD were 61 (40-100) and 53 (40-76) min (p = 0.18), respectively, and no significant differences were observed between the groups. Subgroup analysis showed that the median procedure times for patients with a lesion diameter of ≥30 mm in the C-ESD and T-ESD groups were 89 (57-80) and 69 (50-104) min (p = 0.05), respectively, and for nonexpert operators were 81 (62-120) and 64 (52-109) min (p = 0.07), respectively.

Conclusions: The traction method did not contribute to a significantly shortened ESD procedure time. However, this method may be useful when the tumor diameter is large or if the procedure is conducted by nonexpert endoscopists.

Background and Aim:ESD is often performed using a clinical pathway schedule in Japan; however, the evidence according to such a pathway was still lacking. Hence, the purpose of this study was to investigate the current status of clinical pathways in specialized facilities that perform numerous ESDs of the colon.

Methods:A questionnaire survey was conducted on common points and adverse events related to ESD in 20 facilities participating in a long-term follow-up study of colon ESD (the Colorectal ESD Activation Team of Japan, CREATE-J).

Results:The median length of hospital stay was 5 days, and in 89.5% of the facilities, ESD was performed on the day after hospitalization, with patients being allowed to start eating on the second day after ESD in 57.9% of the facilities. Fifty-five percent of the facilities strengthened the pretreatment, 60% did not perform a post-treatment radiographic examination, and 60% performed blood tests only on the day after treatment. The frequency of adverse events was as follows: delayed bleeding, 2.2%; delayed perforation, 0.6%; and peritonitis, 0.3%. The corresponding median times to onset of these adverse events were the second day of treatment, 42 h after treatment, and 16.5 h after treatment.

Conclusion:The clinical pathways for ESD in the CREATE-J participating facilities were appropriately designed in terms of hospital stay duration to prioritize patient safety.