Digestive EndoscopyVolume 34, Issue 7 p. 1494-1494 Letters, Techniques and Images Which variable better predicts the risk of lymph node metastasis in T1 colorectal cancer: Highest grade or predominant histological differentiation? Katsuro Ichimasa, Corresponding Author Katsuro Ichimasa ichitommy14@yahoo.co.jp Digestive Disease Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan Department of Gastroenterology and Hepatology, National University Hospital, Singapore City, Singapore Department of Medicine, National University of Singapore, Singapore City, SingaporeSearch for more papers by this authorShin-ei Kudo, Shin-ei Kudo Digestive Disease Center, Showa University Northern Yokohama Hospital, Kanagawa, JapanSearch for more papers by this authorKhay Guan Yeoh, Khay Guan Yeoh Department of Gastroenterology and Hepatology, National University Hospital, Singapore City, Singapore Department of Medicine, National University of Singapore, Singapore City, SingaporeSearch for more papers by this author Katsuro Ichimasa, Corresponding Author Katsuro Ichimasa ichitommy14@yahoo.co.jp Digestive Disease Center, Showa University Northern Yokohama Hospital, Kanagawa, Japan Department of Gastroenterology and Hepatology, National University Hospital, Singapore City, Singapore Department of Medicine, National University of Singapore, Singapore City, SingaporeSearch for more papers by this authorShin-ei Kudo, Shin-ei Kudo Digestive Disease Center, Showa University Northern Yokohama Hospital, Kanagawa, JapanSearch for more papers by this authorKhay Guan Yeoh, Khay Guan Yeoh Department of Gastroenterology and Hepatology, National University Hospital, Singapore City, Singapore Department of Medicine, National University of Singapore, Singapore City, SingaporeSearch for more papers by this author First published: 18 August 2022 https://doi.org/10.1111/den.14422Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume34, Issue7November 2022Pages 1494-1494 RelatedInformation

Third-space endoscopy, also known as submucosal endoscopy, allows for a wide range of therapeutic interventions within the submucosal layer and even into the muscular or subserosal layers of the gastrointestinal lumen. The technical development of peroral endoscopic myotomy (POEM) for achalasia has revolutionized the field of therapeutic endoscopy and the method has been continuously refined and modified. Although POEM has been applied to treat primary achalasia, it shows a favorable clinical response in other esophageal motility disorders and as a salvage treatment after previously failed intervention. Gastroesophageal reflux after POEM has drawn considerable attention and there have been major advancements in its prevention and management. POEM has led to advantageous derivatives such as peroral endoscopic tumor resection or submucosal tunneling endoscopic resection for resection of subepithelial lesions, Zenker POEM for hypopharyngeal diverticula, diverticular POEM for epiphrenic esophageal diverticula, and gastric POEM for refractory gastroparesis. These techniques have a similar concept, which constitutes submucosal tunneling with a mucosal flap valve and secure mucosal incision closure. The submucosal tunneling technique is widely accepted and continues to evolve. This study aimed to review in detail the indications, outcomes, and technical variations in POEM and explore several emerging submucosal tunneling procedures. This review will benefit future studies by providing a summary of recent developments in this field.

To evaluate the safety and efficacy of a new endoscopic duodenal-jejunal bypass sleeve (DJBS) in obese patients with nonalcoholic fatty liver disease (NAFLD), while in situ for 3 months, and at 6 months postexplantation. Patients with obesity and NAFLD were enrolled in this single-center, prospective study, wherein the TONGEE DJBS (Tangji Medical, Hangzhou, China) was implanted for 3 months. Primary outcomes were weight loss and changes in hepatic steatosis. Secondary outcomes included changes in liver enzymes, glycemic control, and lipid profile and device safety. Twenty-six patients (age 35.2 ± 7.2 years; 61.5% women) underwent DJBS implantation. At 3 months, bodyweight change from baseline was -8.0 ± 3.6 kg (P < 0.001), corresponding to 8.9 ± 4.0% of total bodyweight. Hepatic steatosis significantly improved based on controlled attenuation parameter, hepatic steatosis index, and fatty liver index (P < 0.001). Liver enzymes, insulin resistance, and metabolic parameters were also improved. At 6 months postexplantation, weight loss and improvements in hepatic steatosis and liver enzyme levels remained statistically significant. Only one patient had a serious adverse event, namely, upper gastrointestinal hemorrhage. Three-month TONGEE DJBS implantation resulted in significant weight loss and improvement in hepatic steatosis, liver enzymes, insulin resistance, and metabolic parameters in obese patients with NAFLD. Randomized controlled trials are required to further elucidate these initial findings.

Although a large‐caliber endoscope (LCE) is indispensable for through‐the‐scope placement of a self‐expandable metallic stent (SEMS) in patients with malignant colonic obstruction (MCO), inaccessibility of the target obstructing lesion (TOL) by the endoscope is a significant cause of unsuccessful procedures. We herein present a novel salvage procedure when the TOL is not directly accessible by an LCE in conditions such as coexisting peritoneal carcinomatosis involving the colon. The salvage procedure, termed over‐the‐catheter endoscope replacement (OCER), starts with an ultraslim endoscope suitable for deep insertion beyond a tortuous colon for traversing a guidewire through the TOL. The ultraslim endoscope is then withdrawn and replaced by an LCE through the following steps. An endoscopic retrograde cholangiopancreatography catheter is preloaded in the LCE, the catheter alone is passed over the guidewire already traversed through the TOL, and the LCE is navigated over the catheter as far as possible toward the TOL to deliver the SEMS delivery system in a standard through‐the‐scope manner or further in an over‐the‐wire manner even if LCE insertion is incomplete. Among the 165 patients with MCO who underwent stenting during our study period, OCER led to successful procedures in all nine patients whose TOLs were initially inaccessible because of colon‐involving peritoneal carcinomatosis. By utilizing the functions of distinctive endoscopes in a unique and complementary way, OCER can be a practical salvage option for challenging cases of MCO that are highly prone to unsuccessful palliation by conventional SEMS placement.

One concern associated with pancreatic diseases is the poor prognosis of pancreatic cancer. Even with advances in diagnostic modalities, risk stratification of premalignant lesions and differentiation of pancreatic cysts are challenging. Pancreatic lesions of concern include intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, serous cystadenomas, pseudocysts, and retention cysts, as well as cystic degeneration of solid tumors such as solid pseudopapillary neoplasms and pancreatic neuroendocrine neoplasms. Pancreatic juice obtained during endoscopic retrograde cholangiopancreatography has previously been used for the detection of KRAS mutation. Recently, duodenal fluid, which can be obtained during the relatively minimally invasive procedures of endoscopic ultrasound (EUS) and esophagogastroduodenoscopy, and cyst fluid collected by EUS-guided fine-needle aspiration (FNA) were used for molecular biological analysis. Furthermore, advanced analytic methods with high sensitivity were used for the detection of single and multiple markers. Early detection of malignant pancreatic tumors and risk stratification of premalignant tumors can be performed using duodenal fluid samples with a single marker with high sensitivity. Technological advances in simultaneous detection of multiple markers allow for the differentiation of cystic pancreatic tumors. One thing to note is that the clinical guidelines do not recommend pancreatic cyst fluid and pancreatic juice (PJ) sampling by EUS-FNA and endoscopic retrograde cholangiopancreatography, respectively, in actual clinical practice, but state that they be performed at experienced facilities, and duodenal fluid sampling is not mentioned in the guidelines. With improved specimen handling and the combination of markers, molecular markers in PJ samples may be used in clinical practice in the near future.

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