With increasing recognition of Endo-Hepatology, the role of EUS in managing liver diseases has gained substantial attention. In diffuse liver disease, EUS-guided liver biopsy has demonstrated improved specimen quality through advances in needle design and suction techniques, with diagnostic performance comparable to that of percutaneous liver biopsy. EUS is also effective for detecting and obtaining tissue from small liver lesions and offers particular clinical utility when percutaneous approaches are difficult, such as in patients with ascites or lesions in the caudate lobe. Furthermore, emerging techniques, including EUS-guided portal pressure gradient measurement and portal venous blood sampling, have broadened the applications of EUS-based diagnostics. This article reviews the current status and future perspectives of EUS-based diagnosis for liver diseases.

Endoscopic ultrasound (EUS) plays a critical role in the early diagnosis of pancreatic cancer. However, most EUS procedures are performed at major hospitals, where increasing examination volumes have resulted in greater workloads and longer waiting times. This article summarizes the role of EUS in the early diagnosis of pancreatic cancer, the current status of hospital-clinic collaboration, and the significance and challenges of introducing EUS into clinics. The availability of EUS in clinics may facilitate the rapid evaluation and diagnosis of high-risk patients, shorten the interval from diagnosis to treatment initiation, and reduce the burden on major hospitals. However, several challenges remain, including substantial capital investment, difficulties in securing specialists, and limited supporting evidence. Future advances in community-based systems for the early diagnosis of pancreatic cancer are expected through expanded insurance coverage, enhanced image sharing, and broader adoption of AI-assisted diagnostic technologies.

An 80-year-old woman was found to have a 20mm submucosal lesion with a steep rise and an apical depression in the greater curvature of the gastric fundus. Upper gastrointestinal endoscopy and EUS revealed a heterogeneous, hypoechoic mass confined to the third layer, with luminal structures and cystic components, suggesting ectopic pancreas. To confirm, differentiation from GIST and gastric malignant lymphoma was required. Biopsy from apical depression tissue and EUS-FNA revealed pancreatic acini and ductal components, leading to a diagnosis of Heinrich type Ⅱ ectopic pancreas. To date, few reports describe ectopic pancreas occurring in the gastric fundus. Among these, most cases have been diagnosed after surgical resection. In this case, definitive diagnosis of ectopic pancreas occurring in the gastric fundus was made possible by EUS-FNA.

A 73-year-old male with a history of surgery for advanced gastric cancer underwent routine follow-up ２ years and ６ months postoperatively, during which a fecal occult blood test was positive. Colonoscopy revealed a submucosal tumor-like lesion in the transverse colon, which was diagnosed as recurrent gastric cancer with colonic metastasis. The lesion progressively enlarged and caused colonic obstruction, prompting placement of a self-expandable metallic stent. The patient subsequently received chemotherapy and was later transitioned to palliative care. No recurrent colonic obstruction developed, and the patient died from disease progression １ year and ２ months after stent placement. Colonic metastasis from gastric cancer is a rare form of distant metastasis and is generally associated with a poor prognosis. When obstruction occurs, palliative decompression is essential. To date, no reports have described colonic stent placement for colonic stenosis caused by metastatic gastric cancer. In patients with limited life expectancy, colonic stenting may provide a minimally invasive option for symptom relief.

This report describes a rare case of early colorectal cancer exhibiting an inverted growth pattern. A male in his 60s underwent colonoscopy following a positive fecal occult blood test, which revealed a 15-mm elevated lesion in the sigmoid colon. The lesion appeared as a submucosal tumor with a central, sharply demarcated depression. Magnifying narrow-band imaging revealed irregular-caliber, tortuous vessels in the depressed area (Japan NBI Expert Team classification: type 2B), and crystal violet staining demonstrated a mildly irregular pit pattern (Vi). Although deep submucosal invasion was suspected, the lesion was mobile and lacked features such as fold convergence or stiffness. Therefore, endoscopic submucosal dissection (ESD) was performed for diagnostic and therapeutic purposes. Histopathological examination revealed a well-differentiated adenocarcinoma confined to the mucosa (pTis), measuring 13×10 mm, with no lymph vascular invasion and negative resection margins. The tumor exhibited an unusual pattern of mucosal infolding with downward growth, displacing the muscularis mucosae into the submucosa without true submucosal invasion. Desmin staining confirmed the preservation of the muscularis mucosae, although it was thinned and inverted. These findings were consistent with an inverted growth pattern mimicking deep invasion. Including the present case, only six cases of colorectal cancer with a confirmed inverted growth pattern have been reported to date. Although rare, this growth pattern can endoscopically resemble invasive carcinoma, making preoperative assessment of invasion depth challenging. Recognition of this entity is important because it may help prevent overtreatment of intramucosal cancer. In diagnostically challenging cases such as this, ESD provides both accurate diagnosis and curative treatment.

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and rapid on-site evaluation (ROSE) are well-established techniques for the definitive diagnosis of solid pancreatic tumors, gastrointestinal subepithelial lesions, enlarged lymph nodes, and retroperitoneal tumors. However, endoscopists seldom perform specific specimen preparation or directly assess cytological specimens. In this article, we describe the key aspects of optimal specimen preparation and the cytological features observed during ROSE, with a focus on pancreatic lesions.

Endoscopic management of common bile duct stones in patients with surgically altered anatomy remains challenging. Although balloon enteroscopy-assisted ERCP（BE-ERCP）has become widely used, we still encounter cases in which reaching the papilla or a hepaticojejunostomy anastomosis is difficult as well as cases in which complete stone clearance cannot be achieved. Antegrade stone management through an access route created by endoscopic ultrasound-guided biliary drainage（EUS-BD）or an EUS-guided created route（ESCR）, namely EUS-guided antegrade stone management（EUS-AG）, is a promising alternative for patients in whom BE-ERCP is difficult. Previous reports have shown comparable technical success rates between EUS-AG and BE-ERCP, and have suggested a shorter procedure time with EUS-AG. The key technical concept is a staged approach: after performing EUS-guided hepaticogastrostomy or, in patients who have undergone total gastrectomy, EUS-guided hepaticojejunostomy, stone extraction is performed after fistula maturation. The papilla or anastomosis is dilated with a balloon and the stones are advanced into the duodenal/intestinal lumen using an antegrade balloon catheter and/or basket catheter. Cholangioscopy-assisted lithotripsy（EHL or holmium-YAG laser）is useful for the treatment of large or multiple stones and intrahepatic stones. This article describes the indications for EUS-AG, provides a practical procedure （including device selection, tips, and technical modifications）, and troubleshooting, and explains the limitations of this approach.

Objectives: The incidence of esophageal adenocarcinoma（EAC）arising in patients with long-segment Barrettʼs esophagus（LSBE）in Japan remains to be elucidated. This study aims to investigate the incidence of EAC in Japanese LSBE cases.

Methods: This is a multicenter prospective cohort study involving 32 hospitals throughout Japan. Consecutive patients with Barrettʼs esophagus with a maximal length of ≥ ３ cm were prospectively enrolled. The study was initiated in June 2011, and the eligible cases were scheduled to undergo subsequent annual endoscopies for 10 years, concluding in December 2021. The cancer incidence was calculated with 95％ confidence intervals and expressed as ％/year of follow-up.

Results: The initial registry comprised 343 participants. After excluding 16 cases with prevalent EAC and 60 cases with < １ year of follow-up, a total of 267 cases with LSBE were followed up for １-10 years （58.0 ± 35.5 months）, making the total patient-years 1290.4. During the observation period, 13 new EACs were identified, leading to an estimated EAC incidence of 1.01（0.57-1.73）％/ year. All the incident EAC cases were diagnosed as early cancers. Individuals who developed EAC demonstrated a higher prevalence of ever smoking （76.9％ vs. 33.5％, p ＝ 0.002） compared to those who did not.

Conclusions: This prospective, 10-year follow-up study revealed a substantial EAC incidence in Japanese LSBE cases, 1.01（0.57-1.73）％/year, similar to values reported in Western countries. This result is a significant indicator for developing effective endoscopy surveillance for Japanese LSBE. UMIN000016043.