Background: ESD under general anesthesia (GA-ESD) is known to improve procedural stability and patient safety. Given the limited availability of operating room, GA-ESD in the endoscopy room has been implemented. This study evaluated its indications and safety.

Methods: We retrospectively analyzed clinical background and perioperative complications in 194 upper gastrointestinal GA-ESD cases (169 in the endoscopy room and 25 in the operating room) between January 2020 and December 2024. High-risk patients for anesthesia underwent ESD in the operating room.

Results: All procedures were completed without intraoperative anesthesia-related complications. Complications occurred in 45 cases (39 in the endoscopy room and 6 in the operating room) and were managed conservatively without severe outcomes.

Conclusion: With appropriate patient selection and anesthesiologist monitored care, GA-ESD in the endoscopy room is a feasible and safe alternative.

We retrospectively analyzed the endoscopic management of upper gastrointestinal foreign bodies at our institution from May 2013 to May 2025. The participants included patients in whom foreign bodies were identified in the esophagus, stomach, or duodenum. We reviewed the types of foreign bodies, procedure duration, and clinical outcomes. Most cases were successfully managed with endoscopic removal; a small proportion required surgical intervention or treatment discontinuation. Only one patient developed a complication that necessitated further management. These findings demonstrate that endoscopic removal is not only highly effective but also remarkably safe for the treatment of upper gastrointestinal foreign bodies and should be considered the first-line therapeutic approach.

Background: Lower participation in population-based endoscopic gastric cancer (GC) screening may lead to missed opportunities for early detection, but its impact on cost-effectiveness is unclear. This study evaluated how declining participation rates influence the cost-effectiveness of the current screening strategy in Japan.

Methods: A Markov model simulated GC progression based on Helicobacter pylori (HP) infection and intestinal metaplasia (IM) in a low-risk cohort (70% HP-negative, 7% IM prevalence). Biennial endoscopic screening from age 50 over 30 years was modeled at participation rates of 100%, 66.7%, 50%, and 40%. Incremental cost-effectiveness ratios (ICERs) were used for comparison. Sensitivity analyses varied HP-negative rates from 0% to 70%.

Results: A 100% participation rate yielded the lowest cost and highest effectiveness. As participation declined, ICERs increased and cost-effectiveness worsened. The detection rate of GC treatable by endoscopy decreased, while surgically treated GC increased. Sensitivity analyses confirmed the superiority of 100% participation.

Conclusion: Declining participation reduces detection of early-stage GC and worsens cost-effectiveness. Maintaining high screening uptake is essential for optimal outcomes.

Background: Cold Snare Polypectomy (CSP) can be technically challenging for diminutive lesions. Deflating the intestinal lumen may facilitate effective snaring; however, it could not be measured objectively and quantify. In this study, we investigated the relationship between intraluminal pressure during CSP and the histopathologic evaluation of resected specimens.

Methods: Intraluminal pressure was measured during CSP. CSP was performed on three colorectal polyps smaller than 5 mm at controlled intraluminal pressures of 13, 7, and 3 mmHg, respectively. Horizontal resection margins were subsequently assessed histologically.

Results: At intraluminal pressures of 13 mmHg and 7 mmHg, histological horizontal margins were unclear. In contrast, at 3 mmHg, the colonic wall was sufficiently relaxed, allowing the lesion to protrude and be resected with surrounding normal mucosa. In this case, the histological horizontal margin was negative.

Conclusion: Reducing intraluminal pressure to 3 mmHg during CSP may improve the complete resection rate by ensuring snaring and negative horizontal margins.

Background: Adequate sedation is essential for endoscopic procedures, but patients at high risk of respiratory depression or airway obstruction have increased risk of hypoxia, making management challenging. High-flow nasal cannula (HFNC) delivers high-flow oxygen with positive airway pressure and may help prevent hypoxia.

Methods: We retrospectively analyzed upper gastrointestinal endoscopic procedures performed at our hospital since January 2025 using HFNC. Sedation methods, HFNC settings (flow rate and FiO₂), respiratory rate, and SpO₂ trends were evaluated.

Results: Two patients underwent endoscopic submucosal dissection (ESD). Initial attempts under midazolam and dexmedetomidine sedation were interrupted due to excessive body movements. On the following day, ESD was reattempted using propofol alone with HFNC. SpO₂ remained above 95% throughout the procedures, and stable sedation without body movement was achieved, allowing safe completion of ESD.

Conclusion: HFNC may be a useful option for sedation management in patients at high risk of hypoxia, enabling safer endoscopic treatment.

Intestinal lymphangiectasia is a disease in which protein-rich lymphatic fluid leaks from dilated lymphatic vessels into the intestinal tract, resulting in Protein-losing gastroenteropathy (PLG), which can be difficult to diagnose. We encountered three cases in which PLG was suspected based on endoscopic findings and confirmed diagnoses of intestinal lymphangiectasia by biopsy. Because protein leakage from the gastrointestinal tract had been observed by protein leakage scintillation assay, upper gastrointestinal endoscopy was performed, revealing scattered white spots or white villi in the duodenum or upper jejunum. Histopathological findings from biopsy samples from the affected site showed lymphatic vessel dilation in the lamina propria and submucosa, confirming our diagnosis of intestinal lymphangiectasia. To differentiate the primary disease of PLG, it is important to recognize that scattered white spots and white villi in the duodenum and small intestine are endoscopic findings characteristic of enterolymphangiectasia, and thus biopsy these tissues.

Background: Total colonoscopy (TCS) after colorectal stenting for bridge to surgery (BTS) in obstructive colorectal cancer has been reported to be effective. However, the factors influencing successful TCS remain unclear.

Methods: This retrospective study analyzed 45 patients who underwent TCS after stenting for BTS between 2016 and 2023, Patients were divided into successful and unsuccessful groups.

Results: The success rate was 73.3% (33/45). Stents placed in non-flexure regions and larger expansion diameters (≥19.6 mm) were significantly associated with successful TCS (p<0.05). The optimal cutoff for stent expansion diameter was 19.6 mm, with a sensitivity of 60.6% and specificity of 83.3%, and an AUC (area under the curve) of 0.737.

Conclusion: Stenting in non-flexure areas and adequate stent expansion are key factors for successful TCS. Pre-procedural assessment of stent expansion diameter can help predict TCS success.

Background: Sigmoid volvulus (SV) is a benign condition, but it frequently recurs. It causes a mechanical obstruction of the intestine, and endoscopic reduction is usually performed. In this study, we analyzed the clinical characteristics of patients with SV treated at our hospital, as well as the outcomes of endoscopic procedures.

Methods: During the study period from April 2019 to December 2024, 14 patients with SV were enrolled in this retrospective study.

Results: The success rate of endoscopic straightening was 56.7%, and the clinical improvement rate was 93.1%. In cases where endoscopic straightening was unsuccessful, water injection and decompression of the dilated intestinal segment proximal to the stricture were often performed. Seven cases were treated with water injection and decompression with the average procedure time of 15.6 minutes without any complications associated with the procedure.

Conclusion: Combination of water injection and decompression can be an effective alternative intervention for emergent purposes with patients who were unsuccessful for endoscopic straightening.

Salvage endoscopic submucosal dissection (ESD) is increasingly used for superficial esophageal squamous cell carcinoma (ESCC) after radiotherapy (RT), particularly for residual lesions. However, RT-induced fibrosis and vascular changes render the procedure technically challenging and increase the risk of complications. Here, we report a case of superficial ESCC treated with RT, in which salvage ESD was performed for a persistent residual lesion. Although en bloc resection was achieved, the patient developed grade I mediastinal emphysema that was successfully managed conservatively with antibiotics. This case highlights the importance of appropriate patient selection, careful intraoperative techniques, and close postoperative monitoring to minimize complications and ensure successful outcomes after salvage ESD for post-RT esophageal cancer.

We retrospectively reviewed the endoscopic findings of Helicobacter pylori (H.pylori)-negative gastric mucosa-associated lymphoid tissue (MALT) lymphomas diagnosed over the past 10 years. The characteristic endoscopic findings of H.pylori-uninfected MALT lymphomas are small, pale, and depressed mucosal lesions that tend to be multiple. These lesions resemble undifferentiated carcinomas, and a tree-like appearance is useful for their diagnosis. Therefore, given the potential for malignancy, thorough endoscopic screening is warranted even in H. pylori-negative cases.

An 85-year-old woman with over 10 years of rabeprazole use developed multiple gastric fundic gland polyps. The largest polyp in great curvature enlarged from 10 mm to 20 mm over one year. Histopathological assessment of the polyp revealed low grade dysplasia, and endoscopic submucosal dissection was planned. However, the polyp with dysplasia could not be detected after the two months of discontinuation of rabeprazole and only the biopsy scar existed. Biopsy of the scar showed no dysplasia. This case suggests careful consideration of timing between PPI cessation and endoscopic intervention when planning diagnostic treatment of PPI-related fundic gland polyps.

A 79-year-old man presented with abdominal pain. Esophagogastroduodenoscopy (EGD) revealed two lesions in the gastric body. Biopsy confirmed a well-differentiated neuroendocrine tumor (NET G1). EGD showed atrophy in the gastric body, but not in the antrum, indicating reverse atrophy typical of autoimmune gastritis (AIG). Based on these endoscopic findings, he was diagnosed as type I gastric NET (G-NET). Endoscopic submucosal dissection (ESD) was performed for both lesions. One lesion was intramucosal, with venous invasion. According to the current guidelines, type I G-NETs without muscularis propria (MP) invasion or lymph node metastasis can be managed without additional treatment. However, recent studies have suggested that venous invasion may be associated with an increased risk of lymph node metastasis. Therefore, careful long-term surveillance was required for him.

An 89-year-old woman presented with hematemesis, and endoscopic examination revealed a hemorrhagic gastric ulcer in the lesser curvature near the cardia. After successful endoscopic hemostasis, vonoprazan was initiated, and the patient was discharged. On follow-up endoscopy on day 57, a yellowish-white exudate was observed at the base of the ulcer. Histological examination confirmed Candida infection. Oral miconazole was initiated, and by day 119, the ulcer healed. Although gastric candidiasis is rare, it may occur not only as an opportunistic infection but also due to low gastric acidity caused by acid-suppressive agents. In this case, vonoprazan likely contributed to Candida overgrowth and delayed healing. Therefore, clinicians should consider the risk of secondary Candida infections when using potent acid suppressants.

A 74-year-old man who had undergone colon cancer surgery at 5 years prior to his presentation was referred by his surgeon for elevated tumor marker. Preoperative examination only revealed atrophic gastritis and a single polyp. Esophagogastroduodenoscopy (EGD) showed hyperplastic polyps over a large area of the gastric body, making it difficult to search for any malignancies. At 3 months after Helicobacter pylori (H. pylori) eradication, remarkable reduction of hyperplastic polyps was observed. Gastric cancer was also detected on the lower gastric body. The average time to the disappearance of gastric hyperplastic polyps after H. pylori eradication reportedly is 7 months. In the present case, EGD was performed at approximately 3 months after confirming eradication, and gastric cancer was found. Therefore, early EGD re-examination after H. pylori eradication is necessary in patients with significant gastric hyperplastic polyps that make the diagnosis of gastric cancer difficult.

We present the case of a woman in her seventies who was hospitalized for chronic gastritis, dyslipidemia, and osteoporosis.

As she had undergone distal gastrectomy for gastric cancer 21 years previously, she underwent esophagogastroduodenoscopic examination once a year, and esophagogastroduodenoscopy (EGD) had recently revealed a yellowish-brown mass in the stomach. Abdominal ultrasonography also showed a mass (diameter, 6 cm) with an acoustic shadow in the stomach. Detailed questioning revealed that she had been consuming one persimmon every day for 3 months. She consumed a total of 900 ml of carbonated water on two days (7 and 13 days after EGD), and abdominal computed tomography and EGD on the 18th and 25th day, respectively, following the previous EGD revealed no mass in the stomach. Thus, the gastric bezoar was considered to have resolved following voluntary intake of carbonated water. The patient remains under regular follow-up.

A 48-year-old woman presented with severe epigastric pain and vomiting. Blood test results were unremarkable. Computed tomography revealed a high-density material in the stomach. Emergency upper gastrointestinal endoscopy revealed two rice cakes in the stomach, one of which was impacted by the pylorus. The impaction was released using the scope, but retrieval was difficult. Therefore, they were fragmented using forceps and a high-frequency snare. Her symptoms resolved promptly after the procedure. Rice cakes are known to cause airway or intestinal obstruction due to their adhesive nature; however pyloric impaction with epigastric pain is rarely reported. Rice cakes are rich in amylopectin, which hardens at lower temperatures and resists digestion. When retained in the stomach, hardened rice cakes can cause gastric ulcers. They need to be removed promptly; however, when retrieval is difficult, fragmentation alone may facilitate passage through the stomach, which relieves symptoms.

An 81-year-old woman presented with liver dysfunction. Endoscopic retrograde cholangiopancreatography revealed a distal bile duct stricture, raising suspicion of malignancy. However, cytology and histology showed no evidence of malignancy, and repeated follow-up evaluations remained non-diagnostic. Thirty months after the initial presentation, she was hospitalized due to obstructive jaundice. Papillary traction was endoscopically observed at the time; however, as before, brush cytology and biopsy failed to confirm the presence of malignancy. Endoscopic ultrasound (EUS) revealed a faint hypoechoic mass at the site of the stricture, and EUS-guided fine-needle aspiration (EUS-FNA) yielded Class V cytology, establishing a definitive diagnosis. We present this diagnostically challenging case of non-exposed ampullary carcinoma in which conventional endoscopic procedures failed to detect the malignancy, thereby highlighting the usefulness of EUS-FNA as a definitive diagnostic tool.

A male in his 90s underwent esophagogastroduodenoscopy (EGD) for upper abdominal pain, which revealed a submucosal tumor-like elevated lesion on the anterior wall of the duodenal bulb. A biopsy identified a neuroendocrine tumor (NET) (G1). Despite his advanced age, contrast-enhanced computed tomography confirmed the absence of metastases, and we performed endoscopic submucosal dissection (ESD). Although the abundant Brunner's glands made submucosal dissection difficult, we completed ESD without complication. Pathology results showed a NET (G1), 7×5 mm, v0, ly0, HM0, VM1. We followed the patient without additional surgical treatment.

Duodenal NETs are rare but have been reported more frequently in recent years. ESD can be considered for lesions less than 10 mm in diameter, and without invasion into the proper muscle layer or lymph node metastasis, but the procedure must be performed by an expert endoscopist.

A man in his 60s, under follow-up by our cardiovascular surgery department, underwent abdominal aortic aneurysm graft replacement in April, year X. In December, he presented with abdominal pain and hematochezia. Labs showed anemia. Contrast CT was inconclusive, but ascending colon diverticula suggested possible diverticular bleeding. He was admitted for colonoscopy the next day.

The following day, he developed hematemesis and hypotension. Emergency upper endoscopy revealed a foreign body protruding into the duodenal lumen from outside the wall (Fig. 2), suspected to be surgical material used to protect the graft. A secondary aortoduodenal fistula was diagnosed, and emergency surgery was performed. Subsequent follow-up CT showed a pseudoaneurysm, prompting transfer for further surgical management.

Case 1: A woman in her 80s and taking aspirin for angina underwent emergency colonoscopy for hematochezia. A diverticulum was found in the terminal ileum, and hemostasis was achieved with clipping. During hospitalization, two additional episodes of hematochezia occurred that required additional clipping. She was discharged on hospital day 16.

Case 2: A man in his 60s taking rivaroxaban for atrial fibrillation underwent emergency colonoscopy for hematochezia, but the bleeding source was not identified. Another episode of hematochezia occurred during hospitalization, and colonoscopy revealed bleeding from a terminal ileal diverticulum. Hemostasis was achieved using clipping and absorbable hemostatic agent. He was discharged on hospital day 10. We experienced two cases of terminal ileal diverticular bleeding that were treated successfully by endoscopic hemostasis. In cases of obscure gastrointestinal bleeding, ileal diverticular bleeding should be considered, with careful inspection of the terminal ileum.

Pyogenic granuloma is a benign vascular lesion that typically arises in the skin or oral mucosa. We present a rare case of small intestinal pyogenic granuloma successfully treated with EMR. A 70-year-old man underwent surgery for strangulated ileus and subsequently developed persistent anemia of unknown etiology. Capsule endoscopy revealed a 10-mm reddish, semi-pedunculated polyp with active bleeding in the distal small bowel. EMR was performed using a transanal double-balloon enteroscopy (DBE). Histopathological analysis confirmed the diagnosis of pyogenic granuloma. Although surgical resection has been the standard approach in most previously reported cases, this case highlights the feasibility and effectiveness of endoscopic resection for such lesions. It also underscores the value of capsule endoscopy and DBE for the diagnosis and minimally invasive management of rare small bowel tumors.

A 66-year-old, male patient who had received an allogeneic hematopoietic stem cell transplantation for mantle cell lymphoma had watery diarrhea due to gastrointestinal graft-versus-host disease (GI-GVHD) and cytomegalovirus (CMV) enteritis. Two months later, the diarrhea recurred with thrombocytopenia, and his activities of daily living (ADL) declined. As colonoscopy was deemed too invasive, small bowel capsule endoscopy (SBCE) was performed and found villous regeneration and map-like ulcers indicating improved GVHD and exacerbated CMV enteritis, respectively. CMV-directed therapy with tapering of GVHD treatment improved the diarrhea and ADL. This case highlights the utility of SBCE as a non-invasive tool for guiding treatment decisions in allo-HSCT patients with a poor, general condition.

Background: An intestinal lipoma can lead to bowel obstruction when it grows larger. We present a case of endoscopic resection of a lipoma caused colonic intussusception to prevent recurrence.

Case presentation: A woman in her fifties had abdominal pain on Day 1. Her symptoms had already improved when she visited our hospital. CT scan did not show obvious blockage. Colonoscopy detected a lipoma measuring about 30 mm in the transverse colon. A lipoma was resected under water endoscopic mucosal resection (UEMR) on Day 10.

Discussion: In the study by Okamoto et al, "80% excisional method", a subtotal tumor resection up to 80% of volume rather than total resection is recommended expectant of thermal energy burning out the remaining tissue. Endoscopic procedures are feasible treatment options.

Conclusion: An endoscopic lipoma resection to prevent recurrent colonic intussusception was performed.

We report the case of a 55-year-old man with a 50-mm submucosal lipoma in the descending colon. Colonoscopy revealed a smooth, yellowish submucosal tumor consistent with a lipoma, which had increased in size compared to findings from 6 years prior. Considering the risk of intussusception, ESD was performed using the ClutchCutter^® to ensure optimal visualization of the incision site and surrounding muscular layer. The tumor was successfully resected without complications. Histopathological examination revealed mature adipocytes with fibrous septa, with no atypical cells, consistent with a benign lipoma. A follow-up colonoscopy conducted one year after the procedure showed only a post-treatment scar with no findings of recurrence. This case highlights the effectiveness and safety of ESD as a minimally invasive approach for large colonic lipomas that might otherwise necessitate surgical resection.

An 85-year-old woman who tested positive for fecal occult blood underwent lower gastrointestinal endoscopy for further investigation. During the procedure, a 1-cm mechanical perforation occurred around multiple sigmoid colon diverticula. Peritonitis was localized, and since our institution did not routinely stock OTSC, conservative management was initially attempted. However, since no improvement in symptoms was observed the day after the perforation, endoscopic closure using OTSC was performed and the procedure was successful. While OTSC closure is typically performed immediately post-perforation, this case suggests that even in facilities that have no OTSC on standby, closure could be feasible the day after perforation in certain cases.

A 35-year-old woman with TACI deficiency, a common variable immunodeficiency (CVID) subtype, was diagnosed after idiopathic colitis. Screening revealed fecal occult blood and colonoscopy showed a 20 mm type 0-Is lesion in the sigmoid colon. Endoscopic submucosal dissection confirmed intramucosal adenocarcinoma with curative resection.

While CVID is linked to malignancies, reports also note colorectal tumors, even in asymptomatic cases. Early detection may lead to favorable outcomes, as shown in this case. Regular endoscopic screening should be considered in CVID patients, regardless of symptoms.

Hypoalbuminemia is rare during remission of ulcerative colitis (UC). We report a 22-year-old man with extensive UC in clinical and endoscopic remission under infliximab treatment who developed hypoalbuminemia (minimum 1.4 g/dl). Colonoscopy revealed multiple pedunculated inflammatory polyps. Protein-losing scintigraphy indicated protein leakage from the colon. Endoscopic resection and ischemic clipping of polyps were performed, resulting in marked improvement in serum albumin. Histology confirmed inflammatory polyps. Previous UC cases with protein-losing enteropathy due to inflammatory polyposis have required surgery. This is the first reported case successfully treated endoscopically. Inflammatory polyps can cause hypoalbuminemia even during remission, and endoscopic removal may be a viable treatment.

Background: Appendiceal bleeding is an extremely rare disease with no established treatment strategy. We report a case of successful endoscopic hemostasis for appendiceal bleeding.

Case presentation: A 73-year-old man presented with hematochezia and syncope. Contrast-enhanced CT showed extravasation at the cecum and appendix. Emergency colonoscopy showed active bleeding from the appendiceal orifice. Hemostasis was achieved by clipping and applying a self-assembling peptide. No rebleeding or appendicitis occurred post-treatment. Considering future risks, laparoscopic appendectomy was performed on the fourth day. Histopathology showed multiple diverticula without a well-defined bleeding source.

Conclusion: Endoscopic treatment for appendiceal bleeding has been rarely reported. Treatment using clips and a self-assembling peptide has the potential to achieve safe and effective hemostasis.

An 80-year-old man underwent a colonoscopy after PET-CT for pulmonary squamous cell carcinoma (cT3N0M0, stage IIB) showed rectal uptake, revealing a 20-mm 0-IIa lesion (Rb). However, the lung cancer treatment was prioritized. Eight months later, another colonoscopy showed lesion progression to 25 mm (0-IIa+Is), and an en bloc endoscopic submucosal dissection was performed. Histological examination revealed a high-grade tubulovillous adenoma with <5% neuroendocrine cell nests confined to the lamina propria. These findings were consistent with composite intestinal adenoma-microcarcinoid, a rare mucosa-confined lesion with a favorable prognosis that is typically identified incidentally on pathological examination.

In Case 1: An elevated lesion was found in the lower rectum (Rb) at a referring hospital. Whereas cold snare polypectomy (CSP) was performed based on the initial diagnosis of adenoma, histopathology showed a neuroendocrine tumor (NET) G1 with a positive vertical margin (PVM). Endoscopic submucosal dissection (ESD) was then performed, and there was a small residual tumor.

In Case 2: A 3 mm elevated lesion was found in Rb at a referring institution. CSP was performed for what appeared to be a rectal submucosal tumor, and histopathology showed a NET G1 with suspected PVM. ESD was subsequently performed, and there was no residual tumor.

All risk factors of lymph node metastasis could not be evaluated due to prior incomplete resection in both cases. Careful evaluation of the lesion and appropriate treatment selection are essential when attempting CSP.