Musculoskeletal disorders (MSDs) among endoscopists, which are caused by awkward body postures and repetitive twisting maneuvers of the wrists, have gained attention in the recent years. This review explains the interpretation of the prevalence and characteristics of MSDs and local body sites, risk factors, including the engagement time and endoscopy environment, and background factors of endoscopists. It also discusses the risk reduction strategy known as the Hierarchy of Controls and ergonomic interventions for endoscopists. Furthermore, the global trends in endoscopy and ergonomics are shared in this review, advocating for a systems approach through collaborations with various stakeholders to improve the field of endoscopy. Thus, it could serve as a guide for numerous gastroenterologists engaged in endoscopic procedures for long durations of time.

Recently, the endoscopic step-up approach has become the standard treatment for pancreatic pseudocysts or walled-off necrosis following acute pancreatitis. This approach involves minimally invasive, endoscopic ultrasound-guided transluminal drainage and, if necessary, direct endoscopic necrosectomy. Endoscopic treatment is now sufficient for a majority of cases, owing to the development of specialized large-bore, bi-flanged metal stents, and endoscopic additional drainage techniques. However, if the disease extends into the pelvic cavity, it is necessary to consider percutaneous or surgical approaches alongside endoscopic treatment. In this article, we review the progress and current status of endoscopic treatment for pancreatic pseudocysts and walled-off necrosis.

An 80-year-old female presented to our hospital with heartburn and hematemesis. Her current medications included minodronate for her osteoporosis. Esophagogastroduodenoscopy revealed circumferential ulceration with severe stenosis, that occluded the passage of an ultrathin endoscope in the lower esophagus. A thorough medical history was acquired, which revealed that she had taken her monthly minodronate tablet with a small volume of water five days prior to the onset of her symptoms. We suspected her esophageal lesion to be minodronate-induced esophagitis. On admission, she was advised fasting and treatment with vonoprazan was commenced. After three days, her symptoms resolved. Ten days post-admission the resolution of her esophagitis was confirmed via repeat endoscopy, and severe stenosis was no longer observed. We herein report a case of minodronate-induced esophagitis with severe stenosis that was revealed endoscopic improvement by observation following identification of the causal drug.

In a 49-year-old woman with gastric cancer scheduled for resection, EGD revealed a hemorrhagic duodenal lymphangioma causing severe anemia. Since pancreaticoduodenectomy for complete resection of the lymphangioma was deemed excessive for this benign disease, only distal gastrectomy for gastric cancer was performed with Billroth-Ⅱ reconstruction, which prevented exposing the lymphangioma to diet and gastric acid. Endoscopic findings indicating bleeding abated postoperatively. No lesion progression or clinical signs of rebleeding were observed during a 3-year follow-up period.

A 64-year-old man with a complaint of loose stools was found to have accumulation of white fluid in the duodenum at the time of EGD. Duodenal biopsies were performed, and histopathological examination revealed sickle-shaped and pear-shaped bodies on the mucosal surface, suggesting Giardia intestinalis. The patient was diagnosed with assemblage A-type G. intestinalis by microscopic examination and PCR-sequencing of duodenal fluid and stool samples. The patient was treated with metronidazole 750 mg/day for 7 days to deworm. After the treatment, the patientʼs stool returned to normal. One year later, EGD was performed, and white fluid accumulation was not observed in the duodenum. G. intestinalis was not detected by microscopic examination of stool samples, duodenal fluid, and duodenal biopsies; hence, it appeared that deworming was successful. G. intestinalis infection should be considered when white fluid accumulation is observed in the duodenum during EGD.

A 66-year-old man was referred to our hospital due to obstructive jaundice. Blood examination revealed a high serum IgG4 level of 262 mg/dl. Contrast-enhanced computed tomography revealed a mass in the perihilar bile duct. No pancreatic enlargement was observed. Histopathological examination of the samples from the transpapillary bile duct biopsy under ERCP showed no tumor cells. IgG4 immunostaining was negative. We performed EUS-FNA of the mass in the perihilar bile duct to obtain samples to reach a definitive diagnosis. Histopathological examination of the samples from EUS-FNA showed stromal infiltration of numerous IgG4-positive plasma cells, leading to the diagnosis of IgG4-related sclerosing cholangitis (IgG4-SC). IgG4-SC located in the perihilar bile duct without autoimmune pancreatitis is referred to as isolated proximal-type IgG4-SC. Isolated proximal-type IgG4-SC is sometimes surgically resected because it is difficult to differentiate from perihilar cholangiocarcinoma. In this case report, we describe a case of isolated proximal-type IgG4-SC diagnosed using EUS-FNA.

Postoperative anastomotic leakage is a major complication of esophageal cancer surgery. To resolve the leakage, conservative management is initially attempted. This entails the administration of antibiotics and wound site drainage. However, closure of the fistula is often difficult to achieve, necessitating further treatment. Endoscopic fistula occlusion using polyglycolic acid (PGA) sheets and fibrin glue has yielded us favorable outcomes in the management of postoperative anastomotic leakage. A crucial aspect of the technique involves pre-soaking the PGA sheets in fibrinogen solution before using them to fill the fistula, subsequently thrombin solution is applied, resulting in a high fistula closure rate.

EUS-FNA is now widely performed to obtain pathological specimens of gastric subepithelial lesion (SEL). EUS-FNA of gastric SEL is mainly performed on mesenchymal tumors such as gastrointestinal stromal tumors (GIST), and requires a sufficient size of specimen for immunohistochemistry. However, specimens from the gastric SEL may be difficult to obtain using EUS-FNA for the following reasons: the lesion often escapes with the gastric wall during the puncture, or the lesion itself is hard and difficult to puncture. Therefore, it is important to devise new aspiration methods such as the slow pull technique and wet suction technique, which have been gaining attention in addition to basic puncture methods such as the door-knocking method and fanning technique. Despite these methods, obtaining a sufficient amount of specimen of gastric SELs has been difficult. Recently, the fine-needle biopsy (FNB) needle and the forward-viewing linear echoendoscope have appeared as revolutionary developments. The FNB needle is a needle with a tip shape designed to enable collection of specimens of adequate quantity and quality. This has recently led to reports that sufficient quantity and quality specimens could be obtained even in SELs of less than 20 mm. In addition, the forward-viewing linear echoendoscope allows for the lesion to be easily approached. Therefore, its usefulness has been reported even for lesions in the greater curvature of the gastric body, where specimen collection has been difficult until now. Furthermore, rapid on-site cytological evaluation (ROSE) is useful in determining whether evaluable specimens have been collected, but it has been reported that a sufficient amount of specimen can be collected without ROSE when an FNB needle is used. It is expected that the diagnostic ability of EUS-FNA in gastric SEL will be improved by further development of equipment and techniques.

Endoscopic submucosal dissection is an established method for complete resection of large and early gastrointestinal tumors. However, methods to reduce bleeding, perforation, and other adverse events after endoscopic resection (ER) have not yet been defined. Mucosal defect closure is often performed endoscopically with a clip. Recently, reopenable clips and large-teeth clips have also been developed. The over-the-scope clip enables complete defect closure by withdrawing the endoscope once and attaching the clip. Other methods involve attaching the clip-line or a ring with an anchor to appose the edges of the mucosal defect, followed by the use of an additional clip for defect closure. Since clips are limited by their grasping force and size, other methods, such as endoloop closure, endoscopic ligation with O-ring closure, and the reopenable clip over-the-line method, have been developed. In recent years, techniques often utilized for full-thickness ER of submucosal tumors have been widely used in full-thickness defect closure. Specialized devices and techniques for defect closure have also been developed, including the curved needle and line, stitches, and an endoscopic tack and suture device. These clips and suture devices are applied for defect closure in emergency endoscopy, accidental perforations, and acute and chronic fistulas. Although endoscopic defect closure with clips has a high success rate, endoscopists need to simplify and promote endoscopic closure techniques to prevent adverse events after ER.