Background and study aim: This international survey aimed to characterize current practice patterns, perceptions, and outcomes related to guidewire use in electrocautery-enhanced lumen-apposing metal stents (EC-LAMS) procedures. Methods: An online survey of experienced therapeutic endoscopists was conducted, collecting information on, preferred techniques, indications for guidewire use, perceived risks, and self-reported adverse events. Post-hoc analyses explored associations between guidewire use, adverse events, and operator experience. Results: Eighty-seven endoscopists (mean age 46.1 years, 88.5% with ≥5 years of EUS experience) completed the survey. Freehand deployment was the preferred technique for the majority of all procedures. Guidewire use was mainly preferred for endoscopic ultrasound guided choledochoduodenostomy (EUS-CDS, 24.1%) and EUS-directed transgastric ERCP (EDGE, 31%). Reported factors favoring guidewire use included small target lumens and difficult scope positioning. Maldeployment was reported as the most important complication, as 49.3%, and 40.6% of the participants reported at least one maldeployment case in EUS-CDS and EUS-guided gastroenterostomy (EUS-GE), respectively. Logistic regression showed guidewire use in EUS-CDS was perceived to result in higher complication rates (44.1% vs 20.0%; OR 3.16, 95% CI 1.08–9.2, p = 0.03). No significant differences in outcomes or guidewire use were observed by operator experience or case volume, although older endoscopists were more likely to use guidewires. Conclusions: Using an international questionnaire for experienced EUS operators, freehand deployment was identified as the predominant technique for EC-LAMS placement.

Endoscopic sphincterotomy (EST) is important in endoscopic retrograde cholangiopancreatography, but bleeding remains its common complication. This pilot study evaluated the efficacy and safety of a self-assembling peptide hydrogel (SAPH; PuraStat) in managing EST-related hemorrhage. A prospective cohort study was conducted from June 2023 to March 2024 at three hospitals in Japan, enrolling patients undergoing EST. Patients were divided into SAPH (received SAPH for EST-related bleeding) and control groups (patients without EST-related hemorrhage); primary endpoint was incidence of delayed bleeding. Of the 254 patients analyzed, 27 were in the SAPH group and 227 in the control group. Background factors related to bleeding were aligned using propensity score matching (PSM). Incidence of EST-related bleeding was 10.6% (27/254). In the SAPH group, 26 of 27 patients (96.3%) achieved successful hemostasis using SAPH alone. Although no delayed bleeding occurred in this group, it occurred in four patients in the control group (1.57%, 4/254). Other adverse events showed no significant difference between the groups. Results were similar to those after PSM and in the subgroup analysis excluding those with self-expandable metallic stent placement. SAPH is a simple, effective, and safe hemostatic option for treating EST-related hemorrhage and may be a promising first-line approach. This pilot study did not demonstrate a significant reduction in delayed bleeding, but absence of delayed bleeding in the SAPH group is noteworthy and suggests a potential preventive benefit. Thus, larger randomized controlled trials are warranted to validate these preliminary findings.

Previous studies in esophagogastroduodenoscopy or colonoscopy have demonstrated positive effects of music on patient anxiety and comfort. This study prospectively evaluated the effect of functional music on sedation requirements and satisfaction during complex endoscopic procedures. A total of 144 patients undergoing endoscopic ultrasound or endoscopic retrograde cholangiopancreatography were prospectively randomized to either a functional music group or a control group without music. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) before the procedure. Sedation depth was monitored with bispectral index (BIS) monitoring. The primary endpoint was the amount of propofol required in mg/kg/min. Secondary endpoints included patient and staff satisfaction. Propofol requirements did not differ significantly between groups (music: 0.15 ± 0.05 mg/kg/min; control: 0.17 ± 0.08 mg/kg/min, P = 0.77). Mean BIS values were similar (music: 60.2 ± 8.4 vs. control: 61.0 ± 8.4, P = 0.74). However, patient satisfaction was markedly higher in the music group (mean value 4.6 ± 0.6 vs. 3.9 ± 0.8, P < 0.00001), as was staff satisfaction (4.8 ± 0.4 vs. 4.1 ± 0.7, P < 0.00001). No adverse events through music intervention occurred. Analysis of PSQI subgroups revealed a trend toward lower propofol use in patients with impaired sleep quality (PSQI > 5) exposed to music, suggesting a possible modulatory effect in this subset. Functional music during complex endoscopic procedures did not reduce propofol consumption but significantly improved satisfaction for both patients and staff. The findings justify implementation of music as a non-pharmacological adjunct to improve patient comfort in endoscopic suites.

Gastric adenoma and cancer are common in Asia, with early detection critical for prognosis. Synchronous multiple early gastric cancers (SMEGCs) occur in 6% to 14% of cases, but their clinicopathological characteristics remain unclear. This study analyzed synchronous multiple gastric neoplasms treated by endoscopic resection or surgery to aid early detection. Among 2,991 cases of early gastric cancer or adenoma diagnosed at our institution, 173 patients with 346 synchronous lesions (January 2016-March 2024) were analyzed. All lesions were mucosal or submucosal. Lesions were categorized as "1st" (larger) and "2nd" (smaller), and clinicopathological characteristics were compared using Chi-square and Fisher's exact tests with Cramér's V. Patients had a mean age of 73.2 years; 72.8% were male. Most lesions were in the lower/middle stomach, differentiated (92.2%), depressed (52.9%), and brownish on narrow-band imaging (65.3%). Mean tumor diameter was 13.4 mm. Although 1st lesions were larger, other features showed high concordance (≥ 0.25 Cramér's V) in location, morphology, histology, invasion depth, and coloration. Survival was 94.8% (nine unrelated deaths). Synchronous multiple gastric neoplasms tend to have similar endoscopic and histopathologic features and often occur within the same belt-like region along the short axis of the stomach. This pattern was named boundary equal lesions trends (BELT). When detecting one lesion, considering BELT is essential.

Background and study aimsOlympus’s new endoscopic system, EVIS X1, features five-LED illumination and a novel complementary metal-oxide-semiconductor (CMOS) image sensor distinct from conventional charge-coupled devices (CCDs), potentially improving colorectal adenoma detection rates (ADRs). This study compared ADR and related indicators between the EVIS X1 system and the conventional EVIS LUCERA ELITE, a xenon-light system.Patients and methodsOf 4,915 colonoscopies performed between September 2020 and April 2023, 814 EVIS X1 and 953 LUCERA cases met inclusion criteria. After propensity score matching to balance baseline characteristics, 660 patients per group were analyzed. Outcomes included ADR, polyp detection rate (PDR), adenomas per colonoscopy (APC), and polyps per colonoscopy (PPC). Subgroup analysis assessed the impact of CMOS-equipped scopes within the X1 group.ResultsADR was slightly higher in the X1 group (36.1%) than the LUCERA group (32.1%), although not statistically significant (P= 0.147). APC (0.77 vs. 0.61,P= 0.034) and PPC (0.95 vs. 0.75,P= 0.023) were significantly higher with X1. Within the X1 group, scopes with CMOS sensors achieved a significantly higher ADR (41.9%) compared with those without. Mean size of polyps detected was smaller with CMOS than with CCD scopes. Multivariate analysis identified age > 60 years, male sex, positive fecal occult blood test, and use of the X1 system with CMOS scopes as independent predictors of higher ADR.ConclusionsThe EVIS X1 system may have the potential to improve adenoma detection, particularly when used with CMOS sensor-equipped scopes. These findings suggest potential benefits for colorectal cancer screening, although further large-scale studies are warranted for validation.

Background and study aimsEsophagogastric junction (EGJ) lesions are uncommon and histologically diverse. Among these, EGJ hyperplastic lesions are rare and generally considered benign. However, their nonspecific appearance makes accurate endoscopic identification challenging. Endoscopic resection is both a diagnostic and therapeutic approach, yet risk factors for neoplastic transformation in EGJ lesions remain unclear. This study aimed to identify predictive factors for neoplastic transformation in hyperplastic EGJ lesions.Patients and methodsThis multicenter, retrospective study included patients with hyperplastic EGJ lesions endoscopically resected across 13 European hospitals. Data were collected from endoscopy and pathology reports. Neoplastic transformation was defined by presence of dysplasia or adenocarcinoma. A multivariable logistic regression model was conducted to assess predictive factors for neoplastic transformation in resected hyperplastic lesions.ResultsFrom January 2015 to October 2024, 91 EGJ hyperplastic lesions were included. Polypectomy/endoscopic mucosal resection (EMR) was performed in 86% of cases, endoscopic submucosal dissection (ESD) in 19%. En bloc resection was successfully achieved in 93% of cases, whereas R0 resection rates were confirmed in 84% of cases. Twenty-one lesions (23%) showed neoplastic transformation on histology. Independent predictive factors for neoplastic transformation in hyperplastic lesions included non-polypoid morphology (odds ratio [OR] 5.48;P= 0.025), presence of surface ulceration (OR 11.5;P= 0.0005) and lesion size (OR 5.48;P= 0.021). Lesion size > 12 mm was identified as a significant predictor of neoplastic transformation in hyperplastic lesions.ConclusionsEGJ hyperplastic lesions showed a non-negligible risk of neoplastic transformation. These findings highlight the need for careful endoscopic assessment to predict malignancy while promoting appropriate management strategies to ensure adequate R0 resection in case of undetected local malignancy.

Background and study aimsThis study aimed to evaluate interobserver and intraobserver agreement in Size/Morphology/Site/Access (SMSA) scoring among practicing endoscopists with varying levels of experience.Patients and methodsA total of 102 fully independent endoscopists participated in the study. Ten short video clips of colonic polyps of varying size and complexity were recorded using Olympus 290 colonoscopes and included white light, near focus, narrow band imaging, and chromoendoscopy where applicable. These videos were embedded in an online questionnaire. Endoscopists were asked to assign SMSA scores based on three variables—size, morphology, and access—with the site provided for standardization. A subgroup of five participants repeated the assessment after 2 to 3 weeks to evaluate intraobserver consistency. Data were analyzed using Fleiss’ kappa via SPSS (v26), and Kappa interpretation followed the Landis and Koch classification.ResultsOverall interobserver agreement for SMSA level across all participants was fair (κ = 0.346). Among individual parameters, morphology had the highest agreement (κ = 0.505, moderate), followed by access (κ = 0.408, moderate) and size (κ = 0.241, fair). Subgroup analysis of experienced endoscopists (> 1000 lifetime colonoscopies) yielded slightly improved kappa values, with morphology still demonstrating the highest consistency. Intraobserver agreement showed moderate to almost perfect reliability for size (κ = 0.444 to 1.000) and moderate to substantial agreement for SMSA level (κ = 0.429 to 0.846).ConclusionsMorphology was the most consistently scored parameter. Although the SMSA tool remains valuable, efforts such as standardized training and simplification of variable categories may be warranted to improve interobserver consistency and enhance clinical-utility.

Background and study aimsEndoscopic transmural drainage with subsequent endoscopic necrosectomy (EN) has become the first-line treatment for acute necrotizing pancreatitis with walled-off necrosis (WON). There is a growing interest in incorporating EN at the index intervention; however, data about the safety of EN are limited. This case series evaluated the rate and type of adverse events (AEs) associated with EN.Patients and methodsWe retrospectively included consecutive patients with WON from 2012 to 2024 who underwent EN in our tertiary referral center. An AE was defined as any event leading to premature cessation of necrosectomy or requiring intervention either during the procedure or within 24 hours of the procedure.ResultsA total of 235 patients and 880 EN procedures (median: 3, interquartile range: 2–5) were recorded. The median age of patients was 57.5 years, of whom 116 were female (49.3%). Snares were used in most procedures (90.9%), EndoRotor in 4.3%, and both were used in 4.8% of procedures. A total of 14 AEs (1.6%) were identified in 11 different patients (4.7%): 13 bleeds and one pneumoperitoneum. In-hospital mortality was significantly higher in the AE group (45.5%) than in the non-AE group (10.3%,P= 0.0004).ConclusionsAEs are rare in EN but are associated with increased mortality.

Background and study aimsLight-emitting diodes are being developed as a light source for an endoscope system instead of xenon lamps, contributing to improved diagnostic capability. This system also has the advantage of consuming less power than a conventional endoscope system using xenon lamps. Power consumption associated with endoscopy is an important factor in reducing greenhouse gas emissions. This study estimated the reduction in greenhouse gas emissions by using a light-emitting diode endoscope system.MethodsWe calculated the power consumption and carbon dioxide emission reduction of the light-emitting diode endoscope system in comparison with a conventional endoscope system using a xenon light source. Calculations were based on actual data regarding operating time and the annual number of endoscopic procedures at Jichi Medical University Hospital. Estimates were also extended to a nationwide scale.ResultsIf each type of endoscope system were used for all endoscopic procedures, the light-emitting diode endoscope system would reduce power consumption by 49% compared with the xenon endoscope system, resulting in a total power reduction of 838.7kWh, equivalent to 394.2 kg of carbon dioxide emissions. In Japan, the total power consumption would be reduced by 53%, corresponding to a total power reduction of 428,628.8 kWh, equivalent to 201,455.5 kg of carbon dioxide emissions.ConclusionsWe estimated the effect of reducing carbon dioxide emissions using the light-emitting diode endoscope system. Wider adoption of the light-emitting diode endoscope system is expected to contribute to usefulness of endoscopic diagnosis and reduction in environmental impact.