Recently, a novel long balloon catheter for tract dilation in endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was developed. The balloon measures 6cm in length, which enables one-step tract dilation of the gastric wall, liver parenchyma, and bile duct wall, contributing to shorter procedure times and reduced bile leakage. This study investigated the feasibility of EUS-HGS with this new balloon catheter. This retrospective study included consecutive cases in which EUS-HGS was performed using a novel long balloon catheter (3mm in diameter) for malignant distal biliary obstructions between February 2024 and October 2024. The patients' clinical background and procedural details were retrospectively examined using medical records. The primary outcome was technical success, defined as successful stent placement without additional dilation using devices other than the new balloon catheter. The secondary outcomes were clinical success and adverse events. This study included 10 patients. The median age was 82.5 years, and there were seven males and three females. The median procedure time was 20min. Technical success was achieved in 90% and clinical success was achieved in 100%. Regarding adverse events, one patient developed moderate cholecystitis, and percutaneous transhepatic gallbladder drainage was performed. No bile leakage, peritonitis, bleeding, or perforation was observed. The new long balloon catheter is an excellent device that can reliably dilate the whole tract with a single inflation. EUS-HGS using a novel long balloon catheter is a feasible treatment option.

ObjectivesAlthough accurate assessment of polyp morphology helps endoscopists select the appropriate management for colorectal polyps, some studies have reported unsatisfactory accuracy in such assessment. This study aimed to clarify the usefulness of a short educational video available on the Internet for accurate polyp morphology assessment.MethodsThis was a multicenter randomized controlled trial. Participants were randomly assigned to the pre‐ or post‐education groups after a pre‐test comprising images of 42 polyps, including 12 laterally spreading tumors. Participants who scored ≥ 80% on the pre‐test were excluded. Only the post‐education group completed the diagnostic test after watching an online educational video. The primary outcome was the difference in diagnostic accuracy between the pre‐test and diagnostic tests for each group.ResultsOf the 296 endoscopists enrolled from 48 institutions, 34 missed the test deadline, and 29 who scored ≥ 80% in the pre‐test were excluded. The primary outcome analysis sets were 117 and 116 in the pre‐ and post‐education groups, respectively. The mean pre‐test accuracies in the pre‐education and post‐education groups were 60.6% and 60.7%, respectively. The difference in diagnostic accuracy between the pre‐test and diagnostic test was significantly higher in the post‐education than the pre‐education group (12.0 points, 95% confidence interval [CI] 9.9–14.1 and 2.3 points, 95% CI 0.9–3.6; p < 0.001).ConclusionThis multicenter randomized controlled trial demonstrated the usefulness of a short educational video for accurate polyp morphology assessment.

ObjectivesIn gastroenterology, sedation demand is increasing, although elderly patients are more prone to experiencing adverse events. Remimazolam, a novel ultra‐short‐acting benzodiazepine, may reduce recovery time after endoscopic procedures.MethodsThis study was a secondary analysis of the investigator‐initiated trial, which investigated the efficacy and safety of remimazolam in gastrointestinal endoscopy (REM‐IICT JP01). Remimazolam sedation was administered during upper gastrointestinal endoscopy. Patients were divided into two groups: 45 non‐elderly and 11 elderly patients (aged ≥65 years). The primary outcome was sedation success. Secondary outcomes included the dose required for sedation, time to awakening, time to regain the ability to walk, and occurrence of adverse events.ResultsEndoscopic sedation was successful in 95.6% of the non‐elderly group and 100% of the elderly group. The total dose of remimazolam was significantly higher in the non‐elderly group (4.0 [3.0–8.0] mg) than in the elderly group (3.0 [2.0–3.0] mg; p < 0.01). The time to awakening was 0.0 (0.0–10.0) min in the non‐elderly group compared to 0.0 (0.0–30.0) min (p = 0.98) in the elderly group. The time to regain the ability to walk was significantly longer in the elderly group (5.0 [0.0–60.0] min) than in the non‐elderly group (5.0 [0.0–30.0] min; p = 0.03). During the procedure, adverse events included hypotension in two cases (4.4%) in the non‐elderly group and hypoxemia in one case (9.0%) in the elderly group.ConclusionsUpper gastrointestinal endoscopy with remimazolam was effective and safe, regardless of age.

A newly developed articulated through-the-scope traction device, TRACMOTION, has been used clinically for endoscopic submucosal dissection (ESD). However, there are few reports on the characteristics of this device and the lesion types for which it is most effective. Therefore, we evaluated its optimal use, efficacy, and safety clinically in animals. Subsequently, we confirmed the safety and efficacy of ESD using this device in humans. Two live swine were used; one underwent conventional ESD (C-ESD) and the other traction-assisted ESD (T-ESD). To examine the traction effect at each resection site, three ESD ulcers (greater curvature/anterior wall/posterior wall) with a diameter of approximately 40mm were created in each swine. Based on our preliminary experiments, scissor-type and needle-type knives were used in the T-ESD and C-ESD groups, respectively. The primary endpoint was the resection speed, and the secondary endpoint was the degree of muscle layer damage. T-ESD was faster than C-ESD on the posterior wall, similar to the greater curvature, and T-ESD was slower than C-ESD on the anterior wall. There were no cases of intraoperative perforations. Obvious muscle layer damage was observed in post-C-ESD wounds on the anterior wall. The submucosal layer was retained in all post-T-ESD wounds. Although this study showed that ESD with TRACMOTION may be safe and effective, it is necessary to consider that it may be unsuitable for some lesions. This may be due to device characteristics and requires further validation.

BackgroundSince it is difficult for expert endoscopists to diagnose early gastric cancer in post‐eradication status, it may be critical to evaluate the stratification of high‐risk groups using the advance of gastric atrophy or intestinal metaplasia. We tried to determine whether the combination of endoscopic artificial intelligence (AI) diagnosis for the evaluation of gastric atrophy could be a useful tool in both pre‐ and post‐eradication status.Methods270 Helicobacter pylori‐positive outpatients (Study I) were enrolled and Study II was planned to compare patients (n = 72) with pre‐eradication therapy with post‐eradication therapy. Assessment of endoscopic appearance was evaluated by the Kyoto classification and Kimura‐Takemoto classification. The trained neural network generated a continuous number between 0 and 1 for gastric atrophy.ResultsThere were significant associations between the severity of gastric atrophy determined by AI endoscopic diagnosis and not having a regular arrangement of collecting venules in angle, visibility of vascular pattern, and mucus using Kyoto classification in H. pylori‐positive gastritis. There were significant differences (p = 0.037 and p = 0.014) in the severity of gastric atrophy between the high‐risk group and low‐risk group based on the combination of Kimura‐Takemoto classification and endoscopic AI diagnosis in pre‐ and post‐eradication status. The area under the curve values of the severity of gastric atrophy (0.674) determined by the combination of Kimura‐Takemoto classification and gastric atrophy determined by AI diagnosis was higher than that determined by Kimura‐Takemoto classification alone in post‐eradication status.ConclusionA combination of gastric atrophy determined by AI endoscopic diagnosis and Kimura‐Takemoto classification may be a useful tool for the prediction of high‐risk groups in post‐eradication status.

Pancreatic fibrosis is one of the main pathological features of chronic pancreatitis (CP), suggesting a strong relationship between CP and pancreatic ductal cancer. There was no available data about pancreatic fibrosis and pancreatic dysfunction in the early CP (ECP) using endosonography (EUS). Asymptomatic patients with pancreatic enzyme abnormalities (AP-P; n = 56) and patients with ECP (n = 21) were determined by the absence of abnormal findings on upper gastrointestinal endoscopy, abdominal ultrasonography, and abdominal computed tomography. An Olympus EUS (GF-UCT 260; Olympus) was used to perform EUS. Open software "Image J", developed by NIH, was used to measure the surface area fraction of the designated elastic blue region. The maximum value among the pancreatic head, pancreatic body, and pancreatic tail was defined as the ELST-blue score. The exocrine and endocrine pancreatic functions were evaluated using the N-benzoyl-l-tyrosyl-p-aminobenzoic acid (BT-PABA) test and homeostasis model assessment of β-cell function (HOMA-β) value, respectively. EUS score, lobularity, and hyperechoic foci/strands in patients with ECP were significantly (p < 0.001) higher than those in patients with AP-P. In addition, there were no significant differences in the BT-PABA test (73.1 ± 25.5, 68.5 ± 15.6) and HOMA-β (93.1 ± 67.4, 73.5 ± 139.7) between patients with ECP and AP-P. The ELST-blue score measured by image J as the quantification tool in EUS strain elastography in patients with ECP was significantly higher (p = 0.002) than that in patients with AP-P. Interestingly, the ELST-blue score was significantly associated with HOMA-β in patients with ECP. The ELST-blue score may be a useful tool for the evaluation of endocrine pancreatic dysfunction in the ECP.

Swift and forced COAG with an electrosurgical knife are commonly used for intraoperative hemostasis in colorectal endoscopic submucosal dissection (ESD). If bleeding cannot be stopped using an electrosurgical knife, cauterization is attempted using hemostatic forceps. Since April 2022, our hospital has started using Spray COAG for intraoperative hemostasis for colorectal ESD. This study aimed to provide evidence of the efficacy of Spray COAG for intraoperative hemostasis. Colorectal ESD was performed for 320 lesions at our hospital. Of these, 307 were included; 145 and 162 lesions were operated before and after the introduction of Spray COAG, respectively. Spray COAG was used after the change. The primary endpoint was the change in the frequency of use of hemostatic forceps after the introduction of Spray COAG; the secondary endpoint was the change in the prevalence of postoperative complications after the introduction of Spray COAG. It should be noted that the Spray COAG mode was employed solely for hemostasis and not for dissection, while the Swift COAG mode was utilized for dissection in the After Spray COAG group. Statistical analysis was conducted using IPTW analysis. The frequency of use of hemostatic forceps was significantly decreased after the introduction of Spray COAG (odds ratio = 0.12, 95% confidence interval [95%CI]: 0.06-0.23, p < 0.001). The prevalence of post-ESD electrocoagulation syndrome significantly decreased (odds ratio = 0.43, 95%CI: 0.22-0.88, p = 0.02). No significant differences were observed between the intraoperative and postoperative perforations or rate of postoperative bleeding. Spray COAG reduced the frequency of hemostatic forceps use in colorectal ESD.

Peribiliary glands are complex lobular structures containing mucus and serous glands, distributed along the extrahepatic and intrahepatic bile ducts. In this report, we describe a case of intraductal papillary neoplasm of the bile duct suspected to be of peribiliary glands origin. The patient was an 80-year-old man who was referred to our hospital for a hepatic mass. On further examination, a 38 × 34 mm cystic lesion with papillary growth was found in S1/4. Because the lesion was extensively bordered by both hepatic ducts and the connection was unclear, it was difficult to determine the extent of hepatic resection. To confirm the location, a peroral cholangioscopy was performed. The connection with the cyst was detected in the right hepatic duct and a villous tumor mucosa protruded through the conduit lumen. Since we found that the lesion communicated with the right hepatic duct, a right hepatectomy was subsequently performed. The postoperative pathological diagnosis was an intraductal papillary neoplasm of the blie ductwith associated invasive carcinoma. The postoperative course was good, and the patient experienced no recurrence.

The effectiveness and safety of propofol-based sedation and midazolam sedation in pediatric bidirectional endoscopy were compared. We retrospectively analyzed the cases of pediatric patients (≤15 years old) who had undergone bidirectional endoscopy, esophagogastroduodenoscopy, and colonoscopy by pediatric gastroenterologists. Demographic data, indications, sedatives/dosages, clinical outcomes, endoscopic findings, adverse events, and total patient time requirements (total time in which patients stay in our hospital) were compared in the two sedation groups. Ninety-one children (51 boys, 40 girls, mean age 13 years, range 9-15) treated at our hospital were enrolled. Propofol alone or in combination with midazolam and/or pentazocine was administered to 51 patients (propofol-based sedation group). Midazolam alone or in combination with pentazocine was administered to the other 40 patients (midazolam sedation group). In the propofol group, the following mean doses were used: propofol, 96 mg (range 40-145 mg); midazolam, 4.9 mg (range 3-5 mg); and pentazocine, 7.5 mg. In the midazolam group, the mean doses of midazolam and pentazocine were 6.2 mg (range 4-10 mg) and 15 mg, respectively. All procedures were successfully completed by pediatric gastroenterologists. The total procedure times and endoscopic findings were similar in the two groups, but the median patient time requirement in the propofol group was significantly shorter versus the midazolam group (7.3 h vs. 8.4 h, p < 0.001). No adverse events occurred in either group. Propofol-based sedation in pediatric bidirectional endoscopy was safely and effectively performed by pediatric gastroenterologists, and its patient time requirement was shorter than that for midazolam sedation.

The population-based colorectal cancer screening guidelines in Japan recommend an annual fecal immunochemical test (FIT). However, there is no consensus on the need for annual FIT screening for patients who recently performed a total colonoscopy (TCS). Therefore, we evaluated the repeated TCS results for patients with positive FIT after a recent TCS to assess the necessity of an annual FIT. We reviewed patients with positive FIT in opportunistic screening from April 2017 to March 2022. The patients were divided into two groups: those who had undergone TCS within the previous 5 years (previous TCS group) and those who had not (non-previous TCS group). We compared the detection rates of advanced neoplasia and colorectal cancer between the two groups. Of 671 patients, 151 had received TCS within 5 years and 520 had not. The detection rates of advanced neoplasia in the previous TCS and non-previous TCS groups were 4.6% and 12.1%, respectively (p < 0.01), and the colorectal cancer detection rates were 0.7% and 1.5%, respectively (no significant difference). The adenoma detection rates were 33.8% in the previous TCS group and 40.0% in the non-previous TCS group (no significant difference). Only a few patients were diagnosed with advanced neoplasia among the patients with FIT positive after a recent TCS. For patients with adenomatous lesions on previous TCS, repeated TCS should be performed according to the surveillance program without an annual FIT. The need for an annual FIT for patients without adenomatous lesions on previous TCS should be prospectively assessed in the future.