Japan Gastroenterological Endoscopy Society (JGES) guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment is compared with the Endoscopy-related Societies Worldwide guidelines. The JGES guidelines focus on reducing the risk of thromboembolism occurrence, particularly in the treatment of DOAC withdrawal and resumptive periods. Many aspects with unclear evidences remain, and further investigation is required. Issues that should be resolved eventually include the positioning of cold polypectomy, whether endoscopic treatment is possible under continued P2Y12 antagonists, positioning of heparin replacement in alternative treatment for DOAC withdrawal, and temporary replacement of DOAC for warfarin withdrawal.

The detection rate of ampullary adenomas has increased because of the widespread use of endoscopic screening. Conventionally, laparotomic pancreaticoduodenectomy has been recommended for advanced ampullary adenocarcinoma. However, the management of early asymptomatic ampullary tumors has changed from open surgery to endoscopic resection because of the developed endoscopic techniques and devices. Endoscopic papillectomy is a widespread therapeutic modality for ampullary tumors despite its high-risk endoscopic technique. Japan Gastroenterological Endoscopy Society and European Society of Gastrointestinal Endoscopy published new guidelines, presenting current best practices of endoscopic papillectomy, despite insufficient evidence. This article reviews more recent emerging evidences and offers tips that can help in actual clinical practice.

A 66-year-old woman who developed type I diabetes mellitus at the age of 50 years was referred to our hospital because of gastric submucosal lesion in the stomach. EGD identified a submucosal lesion, approximately 5 mm in diameter, in the lesser curvature of the middle stomach and showed the corpus dominant atrophy and pseudopyloric metaplasia with the corpus posterior walls. She had positive serum anti-parietal cell and anti-intrinsic factor antibodies. Based on endoscopic findings and histological analysis, G1 gastric neuroendocrine tumor (NET) along with autoimmune gastritis was diagnosed. Additional serological analysis revealed chronic thyroiditis, leading to the final diagnosis of type 3 autoimmune polyendocrine syndrome (APS). ESD was performed for the gastric lesion. Histopathological evaluation revealed a G1 NET. This case suggests that gastroenterologists should be aware of APS and perform EGD for patients with slow progressive type I diabetes mellitus and autoimmune gastritis.

Immune checkpoint inhibitors (ICIs) have widely been used in immunotherapy to target programmed cell death-1 (PD-1), PD ligand 1 (PD-L1), as well as cytotoxic T-lymphocyte associated antigen 4 (CTLA-4). ICIs inhibit the signaling from receptors and ligands, thereby helping boost the bodyʼs immune response against cancer cells. Simultaneously, activated T-lymphocytes can recognize and attack the bodyʼs healthy organs, leading to immune-related adverse events (irAEs). Colitis often occurs as an irAE, while gastritis associated with ICIs is infrequent. In the present study, we retrospectively analyzed five patients (one man and four women) diagnosed with gastritis associated with ICIs (irAE gastritis), at Okayama University Hospital between January 2014 and December 2022, to reveal the clinical features of the disease. The primary diagnosis was malignant melanoma in all cases; the average age of the patients was 68.5 years (57-79 years). The ICIs administered at the onset of irAE gastritis were nivolumab and ipilimumab in two patients and nivolumab, ipilimumab, and pembrolizumab, each in one patient. The chief complaints were anorexia (n = 3), nausea (n = 2), vomiting (n = 2), diarrhea (n = 2), abdominal distension (n = 1), and abdominal pain (n = 1). CT showed thickening of the gastric antrum in one patient, while the remaining four patients had no notable findings in the upper gastrointestinal tract. On EGD, irAE gastritis showed rough mucosa (n = 4), white exudates (n = 4), redness (n = 4), friable mucosa with spontaneous bleeding (n = 4), edematous mucosa (n = 1), and small ulcers (n = 1). Magnifying observation of the gastric lesions was performed in four cases and revealed the disappearance of ductal structures in all cases. Subjective symptoms improved in all patients after the administration of steroids.

An-83-year-old man with a history of distal gastrectomy for duodenal ulcer was admitted to our hospital because of a gastric tumor. EGD revealed a 30-mm elevated lesion on the oral side of the gastroduodenal anastomosis. A biopsy revealed adenocarcinoma, tub2/por1, and ESD was scheduled. One month later, on the day of ESD, the morphology had changed; however, ESD was performed, and histopathological evaluation revealed an adenocarcinoma with enteroblastic differentiation (ACED). The patient did not wish for further surgery despite the presence of a 600-μm submucosal and vascular invasion. Seven months later, a 10-mm raised lesion appeared in the post-ESD ulcer scar, and a biopsy revealed ACED recurrence. Two years later, the tumor spread to the entire stomach; then, the patient developed multiple liver metastases and died. ACED is difficult to diagnose on preoperative biopsy. However, if the histopathological examination after resection reveals tumor cells with clear cytoplasm, immunostaining including SALL4 should be performed to consider the possibility of ACED.

A 46-year-old female patient presented to our hospital for close examination and treatment after a rectal mass was observed during a CS performed at another hospital. On repeat CS, we observed a 10-mm, submucosal, tumor-like mass in the lower rectum. EUS showed a 10-mm hypoechoic tumor located in the submucosa. We performed ESD because the boring biopsy specimens showed nonspecific pathologic findings. Pathological examination of the resected lesion confirmed the diagnosis of colitis cystica profunda.

Goto et al. developed an endoscopic hand-suturing (EHS) technique using a flexible endoscopic needle holder and sutures with anti-reversal barbs for mucosal defects after endoscopic treatment of early-stage gastrointestinal cancers.

We examined five cases, three gastric and two colorectal cancers, in which we performed EHS using EHS devices (SutuArt^Ⓡ) at our hospital. An early phase case showed wound dissection, but EHS was completed in all cases, and no post-procedure complications occurred. The resection and suture times for each lesion were similar, and suture time per stitch may shorten as the number of procedures increase. Although EHS is clinically promising, adequate preparation using a training model is necessary for its new introduction.

Gastric X-ray screening is rapidly replacing EGD screening in population-based gastric cancer screening. An EGD is necessary to ensure minimal patient discomfort and achieve high accuracy. There were concerns about the accuracy of ultrathin transnasal endoscopes because of their inferior image quality compared to oral endoscopes. However, OLYMPUS GIF-1200N and Fujifilm Medical EG-840N, which were released in 2020 and 2022, respectively, are third-generation high-definition ultrathin endoscopes with image qualities equivalent to that of oral endoscopes and considered promising scopes for future gastric cancer screening. Here, we will explain the precautions and tips for evaluation in endoscopy using high-resolution transnasal ultrathin endoscopes.

Biliary stricture is frequently encountered in routine practice, and at times a distinction between benign and malignant biliary strictures is challenging. Confocal laser endomicroscopy (CLE) is expected to overcome this situation. This method generates real-time microscopic images of the bile duct tissue by using a dedicated confocal miniprobe that enables in vivo histological assessment, termed as “virtual biopsy”. However, these procedures are often performed under fluoroscopic guidance through a catheter during ERCP. Therefore, there is uncertainty regarding the proper application of the confocal miniprobe to the site of interest. The confocal miniprobe may be applied accurately to the site of interest using peroral cholangioscopy (POCS). Here, we discuss the usefulness and procedure of probe-based CLE under the direct view of POCS for biliary strictures.

Objectives: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) plays a crucial role in the diagnosis of pancreatic tumors. The present study aimed to investigate the current status of needle tract seeding (NTS) after EUS-TA of pancreatic tumors based on a nationwide survey in Japan.

Methods: Patients who underwent surgical resection of primary pancreatic tumors after EUS-TA performed between April 2010 and March 2018 were surveyed. The incidence rates of NTS were determined, and compared in patients with pancreatic ductal adenocarcinomas (PDACs) and other tumors, and in patients who underwent transgastric and transduodenal EUS-TA of PDACs. The detailed features and prognosis of patients with NTS were also assessed.

Results: A total of 12,109 patients underwent surgical resection of primary pancreatic tumors after EUS-TA. The overall incidence rate of NTS was 0.330%, and the NTS rate was significantly higher in patients with PDAC than in those with other tumors (0.409% vs. 0.071%, P = 0.004). NTS was observed in 0.857% of patients who underwent transgastric EUS-TA, but in none of those who underwent transduodenal EUS-TA. Of the patients with NTS of PDACs, the median time from EUS-TA to occurrence of NTS and median patient survival were 19.3 and 44.7 months, respectively, with 97.4% of NTS located in the gastric wall and 65.8% of NTS resected. The patient survival was significantly longer in patients who underwent NTS resection than in those without NTS resection (P = 0.037).

Conclusions: Needle tract seeding appeared only after transgastric not after transduodenal EUS-TA. Careful follow-up provides an opportunity to remove localized NTS lesions by gastrectomy.

From 2019 to 2021, we prospectively investigated gastrointestinal endoscopy-related adverse events during a week arbitrarily determined by each facility during the 3-year period. Moreover, we conducted a retrospective survey of serious adverse events in the past 3 years. Responses were obtained from 1,197 facilities for the 1-week prospective survey. Of 246,627 gastrointestinal endoscopies, the number of adverse events was 668 (0.271%), with eight fatal cases (0.0003%). Preparation-related adverse events were 177 (0.072%), 165 (0.076%) for observation-only gastrointestinal endoscopy, 325 (1.145%) for therapeutic gastrointestinal endoscopy, and one for laparoscopy (1.266%). There were four fatal cases associated with preparation and therapeutic gastrointestinal endoscopy, and the average age of the fatal cases was higher than that of cured cases. In retrospective studies, most cases with serious adverse events were elderly individuals.