Endoscopic injection sclerotherapy with ligation (EISL) is a combined endoscopic treatment that involves endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation. This study aimed to compare the efficacy of conventional EIS and EISL in treating esophageal varices and the usefulness of EISL. A total of 104 cases treated with conventional EIS and 44 cases treated with EISL for esophageal varices were included in the study. The procedure duration, intra-injection volume, and para-injection volume, the success rate of intravascular injection based on variceal type, recurrence-free survival, and post-treatment adverse events were assessed. The procedure duration was significantly shorter in the EISL group (13.1 ± 7.2min) than in the conventional EIS group (20.7 ± 8.0min; p < 0.0001). Additionally, the para-injection volume per session was lower in the EISL group (0.7 ± 1.0mL) than in the conventional EIS group (1.2 ± 1.1mL; p = 0.0426). The intravascular injection success rate was higher in the EISL group for all variceal morphologies, particularly for F1/F2 esophageal varices. In terms of post-treatment adverse events, the frequency of fever was lower in the EISL group than in the conventional EIS group (p = 0.008). There was no significant difference in recurrence-free survival between the conventional EIS and EISL groups. Compared with conventional EIS, EISL required shorter procedure times and reduced paravariceal leakage of the injected sclerosant. EISL also demonstrated higher success rates, particularly for small varices, and fewer post-treatment adverse events.

Various drainage methods have been used for unresectable malignant hilar biliary obstruction (MHBO). However, controlling cholangitis and obstructive jaundice is still challenging. We performed a phase I/II study of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) as primary drainage for MHBO. This prospective Phase I/II study included 20 patients requiring biliary drainage for MHBO recruited from June 2021 to December 2023. The primary endpoint was safety. The secondary endpoints were clinical efficacy, reintervention methods, and frequency. The types of bile duct stenosis were Bismuth type I/II/IIIa/IIIb/IV; 4/1/5/3/7 cases. Fifteen cases (75%) had cholangitis before the EUS-HGS was performed. Technical success rate; 100% (20/20), clinical success rate; 75% (15/20). The four cases in which clinical success was not achieved were Bismuth type IV with cholangitis and obstructive jaundice, and all cases required additional drainage for the right bile duct.Early adverse events were stent migration: one case (severe) and peritonitis: one case (mild). The safety of EUS-HGS for the primary drainage of unresectable MHBO is acceptable. Regarding clinical efficacy, based on the results observed in patients with Bismuth type IV obstruction, we acknowledge that further investigation is warranted. Trial Registration: UMIN-CTR: UMIN000047702.

Choledochoduodenal fistula (CDF) is an abnormal communication between the common bile duct and the duodenum. While gallstones are the primary cause, peptic ulcer-related CDF has become rare due to the widespread antiulcer therapy. Nevertheless, CDF remains clinically relevant as symptoms are often vague and diagnosis is frequently incidental. We report the case of a 79-year-old woman with vomiting, epigastric pain, and back pain due to a refractory duodenal ulcer complicated by CDF. Endoscopic retrograde cholangiopancreatography (ERCP) using a standard duodenoscope was attempted to facilitate fistula closure by biliary stent placement; however, scope passage was prevented by severe duodenal stenosis. Therefore, ERCP was successfully performed using an ultrathin endoscope with a rendezvous technique. A guidewire was advanced through the CDF into the biliary tract and retrieved at the major papilla. Subsequently, a 5-Fr double-pigtail plastic stent was placed in the left intrahepatic bile duct. This approach achieved effective biliary drainage, promoting ulcer healing and complete fistula closure without surgery. The patient was discharged without complications. This case highlights the clinical utility of the ultrathin endoscope-assisted rendezvous ERCP as a minimally invasive option for CDF with duodenal obstruction when conventional ERCP is not feasible.

ABSTRACTObjectivesPost‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a well‐known complication. While most reported risk factors relate to treatment‐naïve papillae, those in patients with post‐endoscopic sphincterotomy (post‐EST) papillae remain unclear. We aimed to identify risk factors for PEP in patients with a history of EST undergoing ERCP for biliary disease.MethodsWe retrospectively analyzed 678 patients with prior EST who underwent ERCP between January 2017 and October 2023. PEP was diagnosed according to established criteria. Logistic regression analyses were performed to identify risk factors. To account for repeated ERCP sessions, additional analyses using cluster‐robust standard errors were conducted. Body mass index (BMI) was evaluated as both a continuous variable and according to World Health Organization categories. Prophylactic rectal diclofenac or intravenous nafamostat mesilate was administered at the operator's discretion.ResultsThe mean age was 75.4 years, and PEP occurred in 4.4%. Multivariate analysis identified female sex (p = 0.016; odds ratio [OR] 2.97), low BMI (p = 0.021; OR 2.94), and prolonged procedure time (p = 0.0048; OR 4.29) as independent risk factors. Operator experience and prophylactic agents were not significantly associated with PEP. In analyses accounting for within‐patient correlation, BMI <18.5 kg/m2 remained significantly associated with PEP (OR 2.73; p = 0.012), whereas associations with sex and procedure duration were attenuated.ConclusionsLow BMI is a consistent risk factor for PEP in patients with post‐EST papillae. The effectiveness of pharmacologic prophylaxis may differ from that in treatment‐naïve papillae and warrants prospective evaluation.Trial RegistrationN/A.

Gastric hyperplastic polyps can cause gastrointestinal bleeding, and their enlargement has been associated with long-term acid-suppressive therapy. Vonoprazan (VPZ), a potassium-competitive acid blocker, provides potent acid suppression and may induce hypergastrinemia, potentially contributing to the growth of hyperplastic polyps. However, clinical information regarding VPZ-associated gastric hyperplastic polyps remains limited. We report three cases of severe bleeding from gastric hyperplastic polyps in patients who were administered VPZ. Case 1 involved a 92-year-old woman who presented with melena and anemia. Endoscopy revealed an 8-cm hyperplastic polyp, and although resection was considered, it was deferred. After switching from VPZ to an H2-receptor antagonist (H2RA), her anemia gradually improved, and the polyp regressed. Case 2 involved a 61-year-old man with hematemesis due to bleeding from multiple hyperplastic polyps. Emergency endoscopic mucosal resection was performed, and markedly elevated serum gastrin levels were noted. Following the replacement of VPZ with an H2RA, the size of the remaining polyps decreased. Case 3 involved a 54-year-old man with anemia and recurrent bleeding from hyperplastic polyps, requiring multiple endoscopic treatments. After VPZ discontinuation and H2RA initiation, the unresected polyps regressed. Two patients were undergoing hemodialysis, which may have exacerbated hypergastrinemia and bleeding. In all three cases, switching from VPZ to an H2RA resulted in the regression of gastric hyperplastic polyps and improvement of anemia. In patients receiving VPZ who develop progressive anemia or bleeding from hyperplastic polyps, discontinuation of VPZ or switching to an H2RA may be effective.

ABSTRACT A 59‐year‐old man presented with left upper abdominal pain. Contrast‐enhanced computed tomography suggested a duodenal intussusception and a mass with mixed fat and soft‐tissue density extending from the duodenal bulb to the descending duodenum. Esophagogastroduodenoscopy identified a giant pedunculated lesion originating from the posterior wall of the duodenal bulb with a focal depressed area and marked redness. Narrow‐band imaging showed no obvious epithelial neoplastic changes. An upper gastrointestinal series demonstrated an elevated lesion approximately 5 cm in size. Based on these findings, we suspected giant duodenal Brunner's gland hyperplasia. Endoscopic resection was performed under general anesthesia due to the risk of intussusception and potential malignant transformation. En bloc resection was achieved using a scissor‐type endoscopic device with traction, and the specimen was safely retrieved under laparoscopic assistance with gentle compression. Histopathological examination revealed lobulated proliferation of Brunner's glands with fibrous septa and adipose tissue in the submucosa, confirming duodenal Brunner's gland hyperplasia.

Delayed bleeding is a major complication of gastric endoscopic submucosal dissection (ESD), particularly in high-risk patients. The reopenable clip-over-the-line method (ROLM) is a novel closure technique, but its durability and preventive effects remain unclear. We evaluated the impact of ROLM on delayed bleeding and sustained closure after gastric ESD in high-risk patients. We retrospectively reviewed gastric ESD cases from April 2021 to December 2024, including only patients with a BEST-J score ≥3, and compared ROLM and non-ROLM groups. In the ROLM group, mucosal closure was confirmed endoscopically on postoperative day 1 (POD1), and clip retention was assessed at 2 months. The primary outcome was delayed bleeding within 28 days. Secondary outcomes included sustained closure on POD1 and clip retention at 2 months. The ROLM group included 21 lesions in 15 patients, and the non-ROLM group included 93 lesions in 72 patients. Delayed bleeding occurred in 0/15 ROLM patients (0%) versus 17/72 non-ROLM patients (23.6%) (p = 0.036). Multivariable models using Firth logistic regression consistently showed a reduced odds ratio (≈ 0.10), although not statistically significant. All ROLM lesions achieved sustained closure on POD1 (100%). At 2 months, 80.9% retained clips. In high-risk gastric ESD patients, ROLM was associated with no delayed bleeding and achieved complete POD1 closure with frequent 2-month clip retention, suggesting a potential for a promising prophylactic strategy.

ABSTRACTObjectivesUnderwater endoscopic mucosal resection (UEMR) is widely performed for colorectal tumors. However, in our experience, it is sometimes difficult to keep a clear endoscopic view underwater, due to dirty fluid inflow or insufficient water pooling after grasping the polyp, or bleeding just after endoscopic resection. To compensate for such challenges, we reported modified UEMR (M‐UEMR) as a procedure for snaring underwater and undergas resection. Therefore, we conducted a prospective clinical trial to investigate the safety and efficacy of M‐UEMR.MethodsThis single‐center prospective study was conducted at Tokushima University Hospital. Patients with 10–25 mm colorectal polyps were enrolled. The polyps were snared underwater, then infused water was removed, and the lumen was inflated with CO2 for resection, as described in our previous report. Measured outcomes were R0 resection rate and adverse events such as bleeding, perforation, and post‐polypectomy syndrome. In addition, we evaluated the en bloc resection rate and thickness of submucosal (SM) tissue of the resected specimens.ResultsForty patients were enrolled, and the R0 resection rate was 80% (95% confidence interval [CI]: 64.4–90.9). No procedure‐related adverse events were observed. En bloc resection was 92.5% (95% CI: 79.6–98.4). The median thickness of SM tissue (range) was 574 µm (241–2632) at the center of the specimen.ConclusionM‐UEMR demonstrated a high R0 resection rate with a safe profile. M‐UEMR is expected to be utilized as an alternative technique to UEMR for colorectal polyps in patients with difficulty maintaining a clear visual field.

ABSTRACTObjectivesThe endoscopic system EVIS X1 with improved image quality has been introduced into clinical practice. We examined whether third‐generation narrow‐band imaging (3G‐NBI) is more effective than white‐light imaging (WLI) for detecting early gastric cancer (EGC).MethodsOur study, performed at a single center, had a parallel‐group, open‐label, two‐arm, randomized, controlled design. Patients who had undergone endoscopic submucosal dissection for EGC were randomly assigned to a group undergoing 3G‐NBI after initial WLI (initial WLI group) or a group undergoing WLI after initial 3G‐NBI (initial 3G‐NBI group). The primary endpoint was the EGC detection rate of the two methods. The secondary endpoints were as follows: proportions of EGC detected and missed lesions, positive predictive value (PPV) for EGC diagnosis, and observation time for WLI and 3G‐NBI.ResultsThe EGC detection rate was 9.0% (17/188) in the initial WLI group and 8.5% (16/188) in the initial 3G‐NBI group. The missed lesion rate was 5.6% (1/18) in the initial WLI group and 0% (0/18) in the initial 3G‐NBI group. The PPV of the initial WLI group was 42.5% (17/40), whereas that of the secondary 3G‐NBI was 25% (1/4). The PPV of the initial 3G‐NBI group was 30.2% (16/53). No biopsies were performed during secondary WLI. The examination times were 274 ± 78.2 and 280 ± 82.9 s for WLI and 3G‐NBI, respectively.Conclusions3G‐NBI was not superior to WLI in detecting EGC. This finding is likely due to improved WLI image quality.

ABSTRACTWe report a rare case of a BRAF V600E‐mutated laterally spreading tumor, granular type (LST‐G), with a neuroendocrine carcinoma (NEC) component in a patient with stage IV colorectal cancer. The patient presented with multiple lymph nodes and liver metastases. Following systemic chemotherapy, significant regression of both the primary lesion and metastases was achieved, enabling successful conversion surgery. Postoperative pathological analysis post‐surgery revealed only well‐differentiated tubular adenocarcinoma, with complete disappearance of the NEC component. Molecular testing confirmed the persistence of the BRAF V600E mutation. The patient remains recurrence‐free two years after surgery. This case highlights the potential for conversion surgery in stage IV BRAF‐mutated colorectal cancer with NEC.