Endoscopic cryoablation is widely used in several countries to eradicate dysplastic Barrett’s esophagus or to relieve the symptoms caused by advanced obstructive esophageal cancer.

The two main cryoablation technologies include spray cryotherapy, which disperses cryogenic gas directly over a wide lesion area, and the cryoballoon ablation system (CBAS), which delivers the gas into an inflated balloon to treat a localized area.

In our country, CBAS is expected to be introduced as a treatment option for locally recurrent or metachronous superficial esophageal cancer arising within scar tissue from prior endoscopic resections, which has become increasingly common in recent years. Therefore, an investigator-initiated trial was conducted to evaluate the safety and efficacy of CBAS.

The study confirmed a high level of safety and favorable treatment outcomes, leading to regulatory approval of the CBAS in June 2024. It is now expected to be offered as an insurance-covered treatment option for patients in whom endoscopic resection is challenging owing to scarring or changes in adjacent tissues.

Pancreatic stones form as chronic pancreatitis progresses and can cause pain due to impaired pancreatic juice outflow. They may also complicate the clinical course by being associated with conditions such as pseudocysts and pancreatic fistulas. The diagnosis of pancreatic stones relies on various imaging modalities, including CT, MRI, and EUS. Symptomatic stones within the main pancreatic duct are considered indications for treatment. A multimodal therapeutic strategy that appropriately combines endoscopic procedures, extracorporeal shock wave lithotripsy, electrohydraulic or laser lithotripsy, and surgical interventions is required. After effective pain relief, follow-up is crucial for preventing recurrence and improving long-term outcomes. This includes assessing pancreatic function, screening for cancer using imaging techniques, and lifestyle modifications. Further evidence on the appropriate selection of treatment modalities and their long-term efficacy is required.

Gastric antral vascular ectasia (GAVE) is endoscopically characterized by a radial or diffuse telangiectasia of the gastric antrum. GAVE is associated with various conditions, including liver cirrhosis, chronic renal failure, aortic valve stenosis, and autoimmune diseases. GAVE is prone to bleeding due to contact with food residue and peristalsis, causing gastrointestinal bleeding and iron deficiency anemia. During EGD, insufflation distends the gastric wall and reduces superficial capillary blood flow, thereby making GAVE less visible. Therefore, these lesions can be misdiagnosed as gastritis on EGD and may not be recognized as a source of obscure gastrointestinal bleeding. If GAVE is observed on EGD without active bleeding, it is often difficult to determine whether it is the cause of the gastrointestinal bleeding and whether hemostatic treatment is necessary.

In this report, we present the cases of two patients who had previously been treated with argon plasma coagulation (APC) for GAVE. Though EGD showed no active bleeding, video capsule endoscopy (VCE) revealed active bleeding from GAVE, confirming it as the bleeding source. The first patient, a 59-year-old male, had melena and hepatic encephalopathy associated with gastrointestinal bleeding. The second patient, a 72-year-old male, had melena and anemia requiring frequent blood transfusions. APC effectively improved anemia and relieved melena in both patients. Therefore, in patients with anemia and melena, when EGD fails to detect active bleeding from GAVE, VCE may aid in identifying small intestinal bleeding and determining whether hemostatic intervention is required.

Here, we report the case of a 55-year-old male patient who presented with vomiting, diarrhea, and weight loss. Abdominal contrast-enhanced CT revealed a mass in the descending colon that was integrated with the jejunum, and CS revealed a type 2 tumor in the descending colon. Amidotriazoic acid contrast showed leakage of the contrast medium into the jejunum, leading to the diagnosis of descending colon cancer, jejunal invasion, and colojejunal fistula. Oral ingestion caused intestinal obstruction; therefore, surgery was recommended. However, the patient refused surgery, and a partially covered stent was placed inside the tumor. As chemotherapy was continued, the colonic stent migrated into the fistula. The stent was difficult to remove endoscopically; therefore, surgery was performed. The treatment of fistulas caused by colorectal malignancy should be considered in subsequent treatments.

A 90-year-old man with bloody stools was admitted to our hospital in April 2023. Active bleeding was observed in the diverticulum at the end of the ileum, and hemostasis was achieved using endoscopic clipping. Endoscopic treatment was difficult due to the narrow working space of the ileum. Fortunately, the bleeding stopped, and the patient was discharged. However, the bleeding recurred. Each time, a detailed endoscopic examination was performed; however, the source of bleeding could not be identified. The patient was admitted for the fourth time because of bloody stools in January 2024. Active bleeding was found in the same area as the ileal diverticulum, where hemostasis was achieved for the first time with an over-the-scope clip (OTSC).

OTSCs have been reported to have a strong hemostatic effect and are safe for the treatment of colonic diverticular bleeding. It is also thought to be useful for the treatment of ileal diverticular bleeding. Here, we report a case of ileal diverticulum bleeding where endoscopic clipping failed due to rebleeding, but hemostasis was achieved with an OTSC. Treatment with OTSC is relatively easy, even in areas where the working space is insufficient, such as the ileum. Here, we report on the procedure with a video.

This article describes two entirely novel precut techniques for biliary cannulation: opening window fistulotomy (OWF) and needle puncture fistulotomy (NPF). Both methods involve incision of the oral protrusion without touching the papillary orifice, potentially minimizing the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis to the greatest extent possible.

OWF involves making a wide “window-opening” mucosal incision on the oral protrusion to expose the submucosal tissue, followed by a deeper incision to directly visualize and access the bile duct. Because the submucosal layer can be dissected under a wide field of view, this technique allows for better control of the incision depth, potentially enhancing safety and improving the success rate of biliary cannulation.

On the other hand, NPF is a versatile technique using a needle-type knife originally designed for endoscopic submucosal dissection (ESD) to create a fistula on the oral protrusion through which biliary cannulation is performed. This technique is also applicable to the small papillae. The primary goal of NPF is not to increase the cannulation success rate but rather to prevent post-ERCP pancreatitis. Although small papillae do not necessarily make cannulation difficult, they may carry a higher risk of post-ERCP pancreatitis. In such cases, primary NPF may be particularly beneficial.

The two techniques introduced in this article are considered clinically valuable for reducing the incidence of post-ERCP pancreatitis. However, unless performed precisely and safely, the expected outcomes cannot be achieved. Therefore, acquisition and mastery of fundamental techniques and adequate training are essential.

Improving the prognosis of pancreatic cancer requires diagnosis and treatment at the earliest possible stage, ideally at stage 0 or Ⅰ. Recently, progress has been made in accumulating cases and advancing diagnostic knowledge for early-stage pancreatic cancer. EUS provides a high detection rate even when CT or MRI cannot visualize a tumor, and is useful for evaluating hypoechoic areas around the pancreatic duct and for surveillance in high-risk individuals. When EUS-guided fine-needle aspiration is inconclusive or technically challenging, such as in stage 0 or small invasive cancers, pancreatic juice cytology via ERCP can aid in diagnosis. In particular, serial pancreatic juice aspiration cytological examination (SPACE) using endoscopic nasopancreatic drainage catheters offers a high diagnostic sensitivity. Combining SPACE with other cytologic methods, such as single-sample or brush cytology, further improves diagnostic accuracy. A multimodal diagnostic approach utilizing both EUS and ERCP is essential for accurate diagnosis and treatment planning in patients with early-stage pancreatic cancer.

Objectives: The risk of postoperative bleeding is high after gastric endoscopic submucosal dissection (ESD) in patients continuously treated with antithrombotic agents (ATAs). The effectiveness of endoscopic hand suturing (EHS) on bleeding after gastric ESD was investigated in patients at high risk of delayed bleeding.

Methods: Patients with neoplasms ≤2cm who underwent gastric ESD and continued to receive perioperative ATAs were enrolled in this multicenter phase Ⅱ study. The mucosal defect was closed with EHS after removing the lesion. Postoperative bleeding rate was assessed for 3-4 postoperative weeks as a primary outcome measure. The technical success of EHS and adverse events were also assessed. Based on expected and threshold postoperative bleeding rates of 10% and 25%, respectively, we aimed to include 48 patients in the study.

Results: A total of 49 patients were enrolled in the study, and 43 patients were finally registered as the per-protocol set. The postoperative bleeding rate was 7.0% (3/43 patients; the upper limit of one-sided 95% confidence interval [CI], 17.1% and 97.5% CI, 19.1%). The upper limits of the CI were below the threshold value (25%), and the postoperative bleeding rate was below the expected value (10%). The technical EHS success rate, closure maintenance rate on postoperative day 3, and postoperative subclinical bleeding rate were 100%, 83%, and 2%, respectively. No severe adverse events related to EHS were observed.

Conclusions: Endoscopic hand suturing may prevent postoperative bleeding in patients undergoing gastric ESD while being treated continuously with ATAs (UMIN000038140).

Trial registration: This study was registered on the University Hospital Medical Information Network before patient recruitment (ID: UMIN000038140).