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This article provides a guide on strategies for effective endoscopic closure of gastrointestinal defects. It emphasizes the importance of understanding the type of defect being treated, such as full-thickness defects or non-full-thickness defects, as this determines the approach and techniques used for closure. The article also discusses the significance of defect location, size, and tissue quality in determining the appropriate tools and devices for closure. It highlights the importance of preprocedural preparation, drainage of fluid collections, reducing downstream obstructions, stent fixation to prevent migration, optimizing fistula closure, and monitoring post-procedure. The article concludes by suggesting the consideration of innovative techniques for complex refractory defects. [Extracted from the article]

Objectives: Based on different physicochemical properties, common submucosal injection solutions could be classified into three categories: normal saline solution (NS), hypertonic solution (HS), and viscous solution (VS). We compared the efficacy and safety of various categories of solutions in this network meta‐analysis of randomized controlled trials (RCTs) to identify the optimal submucosal injection fluid. Methods: PubMed, Embase, Web of Science, and the Cochrane Library were searched for RCTs that compared the efficacy and safety of NS, HS, and VS during endoscopic resection for gastrointestinal (GI) mucosal lesions. Pairwise and network analyses were conducted to determine the ranking of different fluids. Results: Thirteen RCTs were included in the final analysis with 1637 patients (1639 lesions). HS outperformed NS in rates of en bloc (pooled relative risk [RR] 1.50; 95% confidence interval [CI] 1.10–1.90), overall bleeding (pooled odds ratio [OR] 0.33; 95% CI 0.10–0.88; lesions >10 mm OR 4.65 × 10−2; 95% CI 1.10 × 10−3–0.46), and intraoperative bleeding (lesions >10 mm OR 7.10 × 10−6; 95% CI 4.30 × 10−18–0.26). HS showed the highest probability of ranking first in each outcome except for the volume of injection. Although VS was superior to NS in rates of en bloc, overall, and intraoperative bleeding in the lesions >10 mm subgroup, and required less fluid in pooled analysis, it ranked last in cost of submucosal injection solution. Conclusions: Both HS and VS were superior to NS in comparisons of efficacy and safety. Considering the better performance and potentially low cost, HS might be an optimal choice during gastrointestinal endoscopic resection, especially for colorectal endoscopic mucosal resection. [ABSTRACT FROM AUTHOR]

Objectives: Lymphovascular invasion (LVI) is a critical risk factor for lymph node metastasis (LNM), which requires additional surgery after endoscopic resection of T1 colorectal cancer (CRC). However, the impact of additional staining on estimating LNM is unclear. This systematic review aimed to evaluate the impact of additional staining on determining LNM in T1 CRC. Methods: We searched five electronic databases. Outcomes were diagnostic odds ratio (DOR), assessed using hierarchical summary receiver operating characteristic curves, and interobserver agreement among pathologists for positive LVI, assessed using Kappa coefficients (κ). We performed a subgroup analysis of studies that simultaneously included a multivariable analysis for other risk factors (deep submucosal invasion, poor differentiation, and tumor budding). Results: Among the 64 studies (18,097 patients) identified, hematoxylin–eosin (HE) and additional staining for LVI had pooled sensitivities of 0.45 (95% confidence interval [CI] 0.32–0.58) and 0.68 (95% CI 0.44–0.86), specificities of 0.88 (95% CI 0.78–0.94) and 0.76 (95% CI 0.62–0.86), and DORs of 6.26 (95% CI 3.73–10.53) and 6.47 (95% CI 3.40–12.32) for determining LNM, respectively. In multivariable analysis, the DOR of additional staining for LNM (DOR 5.95; 95% CI 2.87–12.33) was higher than that of HE staining (DOR 1.89; 95% CI 1.13–3.16) (P = 0.01). Pooled κ values were 0.37 (95% CI 0.22–0.52) and 0.62 (95% CI 0.04–0.99) for HE and additional staining for LVI, respectively. Conclusion: Additional staining for LVI may increase the DOR for LNM and interobserver agreement for positive LVI among pathologists. [ABSTRACT FROM AUTHOR]

Objectives: Prediction of the risk of esophageal squamous cell carcinoma (SCC) by endoscopic findings without iodine staining, which is irritating to the esophagus, would be beneficial. In a previous retrospective study, we found that multiple foci of dilated vascular areas (MDV) of the esophageal mucosa, seen in narrow‐band imaging (NBI)/blue laser imaging (BLI), are associated with iodine‐unstained lesions and, thus, may be a predictor of esophageal SCC. This prospective study aimed to investigate the association between MDV and metachronous esophageal SCC. Methods: Patients with a history of endoscopic resection for esophageal SCC were included in the study. First, evaluation of the MDV using NBI or BLI was conducted during the initial endoscopy. The patients were then monitored for metachronous esophageal SCC by endoscopic surveillance. The association between the number of MDV and incidence of metachronous esophageal SCC was investigated. Results: From February 2018 to May 2019, 206 patients were enrolled and 201 patients were included in the analysis. Patients were followed up until October 2022. The median (interquartile range) endoscopic follow‐up period was 1260 (1105–1348) days. The incidence of metachronous esophageal SCC at 2 years was 7.1% in patients with MDV ≤4 and 13.9% in patients with MDV ≥5 (P < 0.01). In the multivariate analysis, MDV was an independent predictor of metachronous esophageal SCC, with an odds ratio (95% confidence interval) of 2.37 (1.06–5.31). Conclusion: Multiple foci of dilated vascular area is a useful predictor for stratifying the risk of metachronous esophageal SCC. [ABSTRACT FROM AUTHOR]

Objectives: The resection of vertical margin‐negative submucosally invasive colorectal cancer (CRC) relies on the pathological risk assessment of lymph node metastasis. However, no large‐scale study has clarified the endoscopic resection (ER) outcome for submucosally invasive CRC, focusing on the vertical margin status. This retrospective study aimed to examine vertical margin involvement in ER for submucosally invasive CRC and explore the treatment consequences associated with vertical margin status. Methods: We analyzed 395 submucosally invasive CRC cases in 389 patients who underwent ER at our hospital between 2008 and 2020. The presence of residual tumors and simultaneous lymph node metastasis in patients who underwent additional surgery was assessed and compared between the vertical incomplete ER and the vertical margin‐negative groups. Results: Among the patients, 270 were men, with a median age of 69 years. The vertical incomplete ER rate was 21.5%, with positive vertical margins and unclear vertical margins identified in 12.2% and 9.3% of the cases, respectively. Among 154 patients who underwent additional surgery after ER, the vertical incomplete ER group had a significantly higher residual tumor rate than the vertical margin‐negative group (P = 0.001). The vertical incomplete ER group had a significantly higher lymph node metastasis rate than the vertical margin‐negative group (P = 0.029). Conclusion: This study clarified the substantial risk of vertical incomplete ER in submucosally invasive CRC and revealed the high risk of residual tumor and lymph node metastasis in vertical incomplete ER for submucosal CRC. [ABSTRACT FROM AUTHOR]

Several advanced imaging techniques are now available for endoscopists managing inflammatory bowel disease (IBD) patients. These tools, including dye‐based and virtual chromoendoscopy, probe‐based confocal laser endomicroscopy and endocytoscopy, are increasingly innovative applications in clinical practice. They allow for a more in‐depth and refined evaluation of the mucosal and vascular bowel surface, getting closer to histology. They have demonstrated a remarkable ability in assessing intestinal inflammation, histologic remission, and predicting relapse and favorable long‐term outcomes. In addition, the future application of molecular endoscopy to predict biological drug responses has yielded preliminary but encouraging results. Furthermore, these techniques are crucial in detecting and characterizing IBD‐related dysplasia, assisting endoscopic mucosal resection and submucosal dissection towards a surgery‐sparing approach. Artificial intelligence (AI) holds great potential in this promising landscape, as it can provide an objective and reproducible assessment of inflammation and dysplasia. Moreover, it can improve the prediction of outcomes and aid in subsequent therapeutic decision‐making. This review aims to summarize the promising role of state‐of‐the‐art advanced endoscopic techniques and related AI‐enabled models for managing IBD, paving the way for precision medicine. [ABSTRACT FROM AUTHOR]

Objectives: Endoscopic management of unresectable hilar malignant biliary obstruction (HMBO) is technically challenging, and effectiveness of stent‐in‐stent using large‐cell, metal stents was reported. A new, large‐cell stent with a 6F tapered delivery system was recently developed. The aim of this study was to compare clinical outcomes of slim‐delivery and conventional large‐cell stents. Methods: This was a multicenter retrospective comparative study of stent‐in‐stent methods using slim‐delivery stents (Niti‐S Large Cell SR Slim Delivery [LC slim‐delivery]) and conventional stents (Niti‐S large‐cell D‐type; LCD) for unresectable HMBO. Results: Eighty‐three patients with HMBO were included; 31 LC slim‐delivery and 52 LCD. Overall technical and clinical success rates were 100% and 90% in LC slim‐delivery group and 98% and 88% in LCD group. Use of the LC slim‐delivery was associated with shorter stent placement time in the multiple regression analysis, with a stent placement time of 18 and 23 min in LC slim‐delivery and LCD groups, respectively. The early adverse event (AE) rate of LC slim‐delivery was 10%, with no cholangitis or cholecystitis as compared to 23% in the LCD group. Recurrent biliary obstruction (RBO) rates and time to RBO were comparable between the two groups: 35% and 44%, and 8.5 and 8.0 months in LC slim‐delivery and LCD groups, respectively. The major cause of RBO was tumor ingrowth (82%) in the LC slim‐delivery group and sludge (43%) and ingrowth (48%) in LCD group. Conclusion: Stent‐in‐stent methods using LC slim‐delivery shortened stent placement time with low early AE rates and comparable time to RBO in patients with HMBO. [ABSTRACT FROM AUTHOR]

Objectives: Endoscopic full‐thickness resection (EFTR) is emerging as an effective modality for mucosal and submucosal lesions in the colorectum. In this systematic review and meta‐analysis, we aimed to analyze the success and safety of device‐assisted EFTR in the colon and rectum. Methods: A literature search was performed in the Embase, PubMed, and Medline databases for studies evaluating device‐assisted EFTR between inception to October 2022. The primary outcome of the study was clinical success (R0 resection) with EFTR. Secondary outcomes included technical success, procedure duration, and adverse events. Results: In all, 29 studies with 3467 patients (59% male patients, 3492 lesions) were included in the analysis. The lesions were located in right colon (47.5%), left colon (28.6%), and rectum (24.3%). EFTR was performed for subepithelial lesions in 7.2% patients. The pooled mean size of the lesions was 16.6 mm (95% confidence interval [CI] 14.9–18.2, I2 98%). Technical success was achieved in 87.1% (95% CI 85.1–88.9%, I2 39%) procedures. The pooled rate of en bloc resection was 88.1% (95% CI 86–90%, I2 47%) and R0 resection was 81.8% (95% CI 79–84.3%, I2 56%). In subepithelial lesions, the pooled rate of R0 resection was 94.3% (95% CI 89.7–96.9%, I2 0%). The pooled rate of adverse events was 11.9% (95% CI 10.2–13.9%, I2 43%) and major adverse events requiring surgery was 2.5% (95% CI 2.0–3.1%, I2 0%). Conclusion: Device‐assisted EFTR is a safe and effective treatment modality in cases with adenomatous and subepithelial colorectal lesions. Comparative studies are required with conventional resection techniques, including endoscopic mucosal resection and submucosal dissection. [ABSTRACT FROM AUTHOR]

Objectives: No protocol for esophagogastroduodenoscopic examination of the duodenum has been established. We examined the feasibility and ability to detect neoplasms of a novel duodenal examination protocol. Methods: This was a two‐facility, prospective, observational study. Our protocol, the Seven Pictures Rule (7PR), requires pictures of the following seven locations: anterior and posterior to the bulb, area of and contralateral to the superior duodenal angle, area of and contralateral to the ampulla, and the transverse duodenum. The primary outcome was rate of completion of 7PR. Secondary outcomes were overall rates of detecting neoplasms, rates of detecting neoplasms for each location, examination time, and completion rates for standard or ultrathin endoscopes. Results: There were 1549 participants. The 7PR completion rate was 81.1% and the detection rates of overall neoplasms, adenomas, and carcinomas were 0.84%, 0.71%, and 0.06%, respectively. The area in which most neoplasms was detected was contralateral to the ampulla (69.2%), and the fewest the transverse duodenum (0%). Mean duration of duodenal examination was 53.1 s. Completion rates for standard vs. ultrathin were 84.4% (1077/1276) vs. 65.6% (179/273) (P < 0.01), respectively. Conclusions: Seven Pictures Rule is acceptable for duodenal examination and a potential quality indicator. [ABSTRACT FROM AUTHOR]

Objectives: Subepithelial lesions (SELs) are associated with various endoscopic resection (ER) outcomes and diagnostic challenges. We aimed to establish a tool for predicting ER‐related outcomes and diagnosing SELs and to investigate the predictive value of endoscopic ultrasound (EUS). Methods: Phase 1 (system development) was performed in a retrospective cohort (n = 837) who underwent EUS before ER for SELs at eight hospitals. Prediction models for five key outcomes were developed using logistic regression. Models with satisfactory internal validation performance were included in a mobile application system, SEL endoscopic resection predictor (SELERP). In Phase 2, the models were externally validated in a prospective cohort of 200 patients. Results: An SELERP was developed using EUS characteristics, which included 10 models for five key outcomes: post‐ER ulcer management, short procedure time, long hospital stay, high medication costs, and diagnosis of SELs. In Phase 1, 10 models were derived and validated (C‐statistics, 0.67–0.99; calibration‐in‐the‐large, −0.14–0.10; calibration slopes, 0.92–1.08). In Phase 2, the derived risk prediction models showed convincing discrimination (C‐statistics, 0.64–0.73) and calibration (calibration‐in‐the‐large, −0.02–0.05; calibration slopes, 1.01–1.09) in the prospective cohort. The sensitivities and specificities of the five diagnostic models were 68.3–95.7% and 64.1–83.3%, respectively. Conclusion: We developed and prospectively validated an application system for the prediction of ER outcomes and diagnosis of SELs, which could aid clinical decision‐making and facilitate patient–physician consultation. EUS features significantly contributed to the prediction. Trial registration: Chinese Clinical Trial Registry, http://www.chictr.org.cn (ChiCTR2000040118). [ABSTRACT FROM AUTHOR]

Esophagogastroduodenoscopy (EGD) screening is being implemented in countries with a high incidence of upper gastrointestinal (UGI) cancer. High‐quality EGD screening ensures the yield of early diagnosis and prevents suffering from advanced UGI cancer and minimal operational‐related discomfort. However, performance varied dramatically among endoscopists, and quality control for EGD screening remains suboptimal. Guidelines have recommended potential measures for endoscopy quality improvement and research has been conducted for evidence. Moreover, artificial intelligence offers a promising solution for computer‐aided diagnosis and quality control during EGD examinations. In this review, we summarized the key points for quality assurance in EGD screening based on current guidelines and evidence. We also outline the latest evidence, limitations, and future prospects of the emerging role of artificial intelligence in EGD quality control, aiming to provide a foundation for improving the quality of EGD screening. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to elucidate the clinical course and management of adverse events (AEs) after endoscopic resection (ER) for superficial duodenal epithelial tumors (SDETs). Methods: Consecutive patients who underwent ER of SDETs between January 2008 and July 2018 at 18 Japanese institutions were retrospectively enrolled. The study outcomes included the clinical course, management, and risk of surgical conversion with perioperative AEs after ER for SDETs. Results: Of the 226 patients with AEs, the surgical conversion rate was 8.0% (18/226), including 3.7% (4/108), 1.0% (1/99), and 50.0% (12/24) of patients with intraoperative perforation, delayed bleeding, or delayed perforation, respectively. In the multivariate logistic analysis, involvement of the major papilla (odds ratio [OR] 12.788; 95% confidence interval [CI] 2.098–77.961, P = 0.006) and delayed perforation (OR 37.054; 95% CI 10.219–134.366, P < 0.001) were significant risk factors for surgical conversion after AEs. Delayed bleeding occurred from postoperative days 1–14 or more, whereas delayed perforation occurred within 3 days in all cases. Conclusions: The surgical conversion rate was higher for delayed perforation than those for other AEs after ER of SDETs. Involvement of the major papilla and delayed perforation were significant risk factors for surgical conversion following AEs. In addition, reliable prevention of delayed perforation is required for 3 days after duodenal ER to prevent the need for surgical interventions. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound‐guided gallbladder drainage (EUS‐GBD) has emerged over the last years as an alternative procedure to percutaneous drainage (PT)‐GBD in patients with acute cholecystitis (AC) at high surgical risk. This process has been driven by the advent of lumen‐apposing metal stents (LAMS) with electrocautery‐enhanced capability, which has rendered the drainage procedure easier to accomplish and safer. Studies and meta‐analyses have proven the superiority of EUS‐GBD over PT‐GBD in high‐surgical‐risk patients with AC. Little evidence exists in the same setting that EUS‐GBD compares equally with laparoscopic cholecystectomy (LC). Moreover, EUS‐GBD might theoretically have a possible role in patients at high surgical risk with an indication to undergo cholecystectomy or with a high probability of conversion from LC to open cholecystectomy. Properly designed studies are needed to better clarify the role of EUS‐GBD in these patient populations. [ABSTRACT FROM AUTHOR]

Objectives: The disposable esophagogastroduodenoscopy (EGD) system is a novel endoscopic device which is highly portable and is designed to eliminate the risk of cross‐infection caused by reusable EGD. This study aimed to investigate the feasibility and safety of disposable EGD in emergency, bedside, and intraoperative settings. Methods: This was a prospective, single‐center, noncomparative study. Disposable EGD was used for emergency, bedside, and intraoperative endoscopies in 30 patients. The primary end‐point was the technical success rate of the disposable EGD. Secondary end‐points included technical performance indicators including clinical operability, image quality score, procedure time, the incidence of device malfunction and/or failure, and the incidence of adverse events. Results: A total of 30 patients underwent diagnosis and/or treatment with disposable EGD. Therapeutic EGD was performed on 13/30 patients, including hemostasis (n = 3), foreign body retrieval (n = 6), nasoenteric tube placement (n = 3), and percutaneous endoscopic gastrostomy (n = 1). The technical success rate was 100%: all procedures and indicated interventions were completed without changing to a conventional upper endoscope. The mean image quality score obtained immediately after procedure completion was 3.72 ± 0.56. The mean (± SD) procedure time was 7.4 (± 7.6) min. There were no device malfunctions or failures, device‐related adverse events, or overall adverse events. Conclusion: The disposable EGD may be a feasible alternative to the traditional EGD in emergency, bedside, and intraoperative settings. Preliminary data show that it is a safe and effective tool for diagnosis and treatment in emergency and bedside upper gastrointestinal cases. Trial registration: Chinese Clinical Trial Registry (Trial ID: ChiCTR2100051452, https://www.chictr.org.cn/showprojen.aspx?proj=134284). [ABSTRACT FROM AUTHOR]

The article discusses the use of lumen-apposing metal stents (LAMS) for biliary drainage in patients with obstructions. The technique, known as endoscopic ultrasound guided choledochoduodenostomy (EUS-CDS), has become increasingly popular due to its simplicity and high success rates. The article highlights the need for prevention and treatment of LAMS dysfunction, as well as the importance of identifying risk factors and developing management strategies. The authors emphasize the technical expertise required for the procedure and the potential impact on oncological treatment. [Extracted from the article]

The article discusses the technique of endoscopic full-thickness resection (EFTR) as a method for removing gastrointestinal lesions that cannot be treated with traditional methods such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). EFTR involves using a full-thickness resection device (FTRD) to deploy an over-the-scope clip (OTSC) over the lesion, followed by excision using a preloaded snare. The article provides step-by-step instructions for the EFTR procedure and emphasizes important considerations and precautions. The authors also mention upcoming events and conferences related to gastroenterology. [Extracted from the article]

Watch a video of this article. [ABSTRACT FROM AUTHOR]

Objectives: Optimal management of type 1 gastric neuroendocrine tumors (T1‐GNETs) remains unknown, with few reports on their long‐term prognosis. This study investigated the clinical characteristics and long‐term prognosis of T1‐GNETs. Methods: We reviewed the medical records of patients diagnosed with T1‐GNET during 1991–2019 at 40 institutions in Japan. Results: Among 172 patients, endoscopic resection (ER), endoscopic surveillance, and surgery were performed in 84, 61, and 27, respectively, including 27, 77, and 2 patients with pT1a‐M, pT1b‐SM, and pT2 tumors, respectively. The median tumor diameter was 5 (range 0.8–55) mm. Four (2.9%) patients had lymph node metastasis (LNM); none had liver metastasis. LNM rates were significantly higher in tumors with lymphovascular invasion (LVI) (15.8%; 3/19) than in those without (1.1%; 1/92) (P = 0.016). For tumors <10 mm, LVI and LNM rates were 18.4% (14/76) and 2.2% (2/90), respectively, which were not significantly different from those of tumors 10–20 mm (LVI 13.3%; 2/15, P = 0.211; and LNM 0%; 0/17, P = 1.0). However, these rates were significantly lower than those of tumors >20 mm (LVI 60%; 3/5, P = 0.021; and LNM 40%; 2/5, P = 0.039). No tumor recurrence or cause‐specific death occurred during the median follow‐up of 10.1 (1–25) years. The 10‐year overall survival rate was 97%. Conclusions: Type 1 gastric neuroendocrine tumors showed indolent nature and favorable long‐term prognoses. LVI could be useful in indicating the need for additional treatments. ER for risk prediction of LNM should be considered for tumors <10 mm and may be feasible for tumors 10–20 mm. Trial registration: The study protocol was registered in the University Hospital Medical Information Network (UMIN) under the identifier UMIN000029927. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to demonstrate the feasibility and safety of a novel twin‐grasper assisted mucosal inverted closure (TAMIC) technique for large perforations after gastric endoscopic full‐thickness resection (EFTR) in a porcine model. Methods: Iatrogenic large perforations of the stomach were created and closed by an experienced endoscopist using the TAMIC technique in 12 pigs. Repeat gastroscopy was performed in 4 weeks after surgery to examine the wound sites and then the animals were killed. The primary outcomes were the successful TAMIC closure rate and the complete healing rate. Secondary end points included procedure time of TAMIC, complete inverted healing rate, delayed bleeding rate, and postsurgery perforation. Histologies of the wounds were analyzed by hematoxylin–eosin, Masson trichrome, and immunohistochemistry staining. Results: The median size of the defects was 3.5 (range 2.5–4.5) cm. TAMIC was successfully performed in all the 12 pigs. Complete healing was achieved in 11 pigs 4 weeks after operation as one pig died postsurgery due to severe pneumonia. The median procedure time for TAMIC was 39 (range 23–81) min. The complete inverted healing rate was 45.5% (5/11). No delayed bleeding or postsurgery perforation was observed. Histologic analyses showed that both the epithelium and muscularis mucosae layers were appropriately connected under inverted healing. Conclusions: Twin‐grasper assisted mucosal inverted closure is feasible and safe for closure of large perforations after gastric EFTR and could be a propagable and promising technique for clinical practice. [ABSTRACT FROM AUTHOR]

Watch a video of this article. [ABSTRACT FROM AUTHOR]

In recent years, there have been significant advances in the endoscopic resection (ER) procedures of superficial nonampullary duodenal epithelial tumors (SNADETs). A preoperative endoscopic diagnosis is thus deemed necessary in determining the indication for subsequent ER. For the histologic and endoscopic diagnosis of SNADETs, understanding the mucin phenotype is inevitable. Recently, two diagnostic algorithms for the differential diagnosis of SNADETs from nonneoplastic lesions under magnifying endoscopy with narrow‐band imaging have been proposed. In addition, various endoscopic approaches have been proposed to differentiate low‐ and high‐grade adenomas/carcinomas, including white light endoscopy, magnifying image‐enhanced endoscopy, and endocytoscopy. These methods, however, have not been standardized with respect to the classification of their findings and the validation of their diagnostic accuracy. Moreover, there are still concerns with respect to the histologic criteria required to establish a SNADETs diagnosis. Standardization in the histologic and endoscopic diagnosis of SNADETs is needed. [ABSTRACT FROM AUTHOR]

Management of hilar strictures pose a significant challenge for endoscopists. Several strategies have been demonstrated in the last decade beyond decompression, however, there remains controversy and minimal consensus in the literature. This review seeks to summarize the current literature and discuss emerging therapies, such as photodynamic therapy and radiofrequency ablation. [ABSTRACT FROM AUTHOR]

Objectives: We proposed a novel temperature‐response collagen sol as a submucosal injection agent for endoscopic resection (ER) using pepsin‐solubilized collagen (PSC) and genipin (Ge) in a prior study. This study aimed to evaluate the usefulness and safety of the sol (PSC/Ge) in acute and chronic phase experiments using living animals. Methods: In experiment 1, we performed endoscopic submucosal dissection (ESD) for six pigs using normal saline (NS), sodium hyaluronate (SH), and PSC/Ge. We compared the required amount of each agent per unit area and procedure time. In experiment 2, we created artificial ulcers with endoscopic mucosal resection (EMR) for five pigs using NS and PSC sol. We compared the artificial ulcer residual rate at 7 and 14 days after EMR, and the scarring rate at 14 days after EMR. Results: The required amount of agents per unit area for PSC/Ge (0.8 ± 0.8 mL/cm2) and SH (1.1 ± 0.8 mL/cm2) were significantly smaller than that for NS (1.8 ± 0.7 mL/cm2). The total procedure time did not have a statistical difference. The artificial ulcer residual rates were 47.3 ± 0.7% for NS and 40.3 ± 0.7% for PSC/Ge on day 7 (P = 0.51), and 15.0 ± 0.1% for NS and 10.2 ± 0.1% for PSC/Ge sol on day 14 (P = 0.35). The scarring rate on day 14 was 10% for NS and 20% for PSC/Ge. Conclusion: We demonstrated the feasibility of a novel temperature‐response collagen gel as a submucosal injection agent for ER in the acute and chronic phase animal experiment. [ABSTRACT FROM AUTHOR]

Watch a video of this article. [ABSTRACT FROM AUTHOR]

A study published in Digestive Endoscopy by Tang et al. examined the effectiveness of an aspiration and coagulation (AC) technique in reducing postoperative bleeding in patients who underwent gastric endoscopic submucosal dissection (ESD). The study included 280 patients in the AC group and 516 patients in the control group. The AC group showed significantly lower rates of massive hemorrhage and overall postoperative bleeding compared to the control group. The study highlights the importance of managing postoperative bleeding, which can have serious consequences for patient outcomes. Various prophylactic approaches, such as medication and targeting post-ESD ulcers, are being researched to prevent postoperative bleeding. However, further research, including prospective studies, is needed to address this challenge. [Extracted from the article]

Duodenal endoscopic submucosal dissection (ESD) is a high‐risk technique; however, prophylactic closure of mucosal defects reduces the risk. Unfortunately, we have encountered cases where closure is difficult, especially in large lesions. Therefore, we developed a novel closure technique, a string clip suturing method with an anchor (SCSM‐A). This study aimed to elucidate the feasibility of this method. Five patients underwent this method for the closure of mucosal defects after duodenal ESD. The initial string clip was deployed at the anal end of the mucosal defects and the second clip was deployed at the other end of the mucosal defect. A third clip was deployed on the muscular layer in the middle of the mucosal defect. The free end of the string was pulled, and additional clips were deployed around the first to the third clips for complete closure. Because of grasping the muscle layer, SCSM‐A can be employed for secure closure without creating a pocket. We reviewed the background and clinical course of hospitalization of patients who underwent this method. The resected specimens ranged from 52 to 103 mm in diameter. Complete closure of the mucosal defects was possible in all the cases. There were no adverse events, and no cases required additional treatment. All the patients were discharged within 7 days. The new method achieved secure closure even for large mucosal defects after duodenal ESD. This is a technique that can be applied to other organs, e.g., the colon. [ABSTRACT FROM AUTHOR]

A variety of devices have been developed for interventional endoscopic ultrasound (EUS). EUS‐guided drainage of the bile duct and pancreatic duct, as well as fluid collection adjacent to the gastrointestinal tract, is performed by a procedure involving puncture, guidewire manipulation, tract dilation, and stent placement. Devices specialized for interventional EUS are being developed for each step of the procedure. Mechanical dilators such as bougie, balloon, and electrocautery dilators are used for tract dilation. Various types of plastic stents, self‐expandable metal stents, and lumen‐apposing metal stents specifically designed for interventional EUS are now available, including one‐step devices developed to improve the efficacy and safety of interventional EUS. In addition, radiofrequency ablation and the placement of fiducial markers and radioactive seeds under EUS guidance are now becoming established for pancreatic neoplasms. Such development of specialized devices has expanded the indications for interventional EUS, increased the success rate, and lowered the adverse event rate. [ABSTRACT FROM AUTHOR]

Endoscopic submucosal dissection is an established method for complete resection of large and early gastrointestinal tumors. However, methods to reduce bleeding, perforation, and other adverse events after endoscopic resection (ER) have not yet been defined. Mucosal defect closure is often performed endoscopically with a clip. Recently, reopenable clips and large‐teeth clips have also been developed. The over‐the‐scope clip enables complete defect closure by withdrawing the endoscope once and attaching the clip. Other methods involve attaching the clip‐line or a ring with an anchor to appose the edges of the mucosal defect, followed by the use of an additional clip for defect closure. Since clips are limited by their grasping force and size, other methods, such as endoloop closure, endoscopic ligation with O‐ring closure, and the reopenable clip over‐the‐line method, have been developed. In recent years, techniques often utilized for full‐thickness ER of submucosal tumors have been widely used in full‐thickness defect closure. Specialized devices and techniques for defect closure have also been developed, including the curved needle and line, stitches, and an endoscopic tack and suture device. These clips and suture devices are applied for defect closure in emergency endoscopy, accidental perforations, and acute and chronic fistulas. Although endoscopic defect closure with clips has a high success rate, endoscopists need to simplify and promote endoscopic closure techniques to prevent adverse events after ER. [ABSTRACT FROM AUTHOR]

Management of upper gastrointestinal (UGI) tract gastrointestinal stromal tumor (GIST) has evolved significantly over the past two decades. For GIST size smaller than 5 cm, laparoscopic resection has become the current standard. To avoid postoperative gastric deformity and preserve gastric function, laparoscopic endoscopic cooperative surgery (LECS) was developed and various modifications have been reported and utilized successfully. Pure endoscopic resection techniques have also been reported at a similar period of time, which further push the boundary of incisionless surgery in managing these lesions. Both tunneling and nontunneling exposed type endoscopic full thickness resection are well described procedures for resection of small UGI GIST. In this review, a summary of these procedures is provided, and the pros and cons of each technique from the perspective of a surgical endoscopist are discussed in detail. LECS and endoscopic resection are complementary to each other. The choice of technique should be tailored to the location, morphology, and size of the target lesions, taking into account the experience of the laparoscopic surgeons and endoscopists. [ABSTRACT FROM AUTHOR]

Endoscopic full‐thickness resection (EFTR) using the full‐thickness resection device (FTRD) is an integral part of diagnostic and therapeutic endoscopy. Since its market launch in Europe in 2014, its safety and effectiveness have been proven in numerous studies. Adaptations in design as well as new techniques, such as hybrid EFTR, expand the spectrum of the FTRD system. The following review is intended to provide an overview of the clinical application and current evidence of EFTR with the FTRD system. [ABSTRACT FROM AUTHOR]

Objectives: Limited information is available on the efficacy and safety of endoscopic resection (ER) of gastric submucosal tumors (SMTs) in Japanese endoscopic practice where ER for gastric tumors is extremely popular. Methods: We conducted this study to elucidate the current scenario of ER for gastric SMTs in Japanese endoscopic practice. Patients (from 12 institutions) with gastric SMTs who underwent ER were enrolled from the first case until August 2020. Results: We enrolled 117 patients with 118 lesions. The number of patients who underwent ER increased over the years. The mean endoscopic tumor size was 20 ± 7.2 (8–40) mm. The growth type was primarily intraluminal (90%). The mean resection and wound closure times were 58 ± 38 (range, 12–254) min and 31 ± 41 (range, 3–330) min, respectively. Complete ER was achieved for 117 (99%) lesions. Full‐thickness resection rate was 44%; however, only 12 (10%) patients required abdominal paracentesis for decompression. Endoscopic treatments were completed in 115 (97%) lesions, while three lesions required conversions to laparoscopic surgery due to luminal collapse, uncontrolled bleeding, and difficulty in defect closure. Gastrointestinal stromal tumors were the most common pathology (74%). No recurrence was observed during the mean follow‐up period of 4.3 ± 2.9 years. The 5‐year overall survival rate was 98.9% (95% confidence interval 97.8–100%). Conclusion: Performance of ER for gastric SMTs is increasing in Japan. The technique seems feasible in Japanese endoscopic practice, warranting further validation in a prospective study. Watch a video of this article. [ABSTRACT FROM AUTHOR]

Minimally invasive surgery has emerged as the dominant theme of modern surgery, in which endoscopic surgery plays a key role. The technique of endoscopic surgery has evolved continuously with extensive research, improving the treatment modalities as well as expanding the indications for its use. As an active perforation endoscopic technique, endoscopic full‐thickness resection (EFTR) is mainly used in the treatment of submucosal tumors (SMTs) of the gastrointestinal tract. With decades of evolution, EFTR has gradually developed into a mature endoscopic operation. Based on clinical experience and current research, indications, techniques, clinical outcomes and future perspectives for EFTR are discussed in this paper. We performed a bibliometric study on EFTR literature and showed robust data through a brief meta‐analysis on the topic. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Endoscopic management of biliary diseases in patients with surgically altered anatomy can be challenging because the altered anatomy makes it difficult to insert an endoscope into the biliary orifice. Even if insertion is feasible, the worse maneuverability of the endoscope and the restriction in available devices and techniques could complicate the procedure. Recently, endoscopic ultrasound‐guided antegrade intervention (EUS‐AG) has been reported as a useful management method for biliary diseases, especially in patients with surgically altered anatomy. In EUS‐AG, the biliary disease is managed in an antegrade fashion through a temporal fistula created under EUS guidance between the intrahepatic biliary duct and upper intestine. In this article, we reviewed the current status of EUS‐AG for each biliary diseases, malignant biliary obstruction, bile duct stones, and benign biliary stricture in patients with surgically altered anatomy. [ABSTRACT FROM AUTHOR]

Endoscopic submucosal dissection (ESD) is globally performed to treat early epithelial tumors of the gastrointestinal tract, but delayed perforation is a problematic procedure‐related complication. To address this problem, closure of ESD‐induced mucosal defects with a detachable snare has been reported. However, one problem is that this method usually requires some degree of skill and replacing a single‐channel scope with a two‐channel scope. We developed the clip stopper closure (CSC) method using a detachable snare in combination with the ZEOCLIP, which can be easily performed with a single‐channel scope, for ESD‐induced mucosal defects. Six consecutive cases were treated with this closure method for colonic ESD‐induced mucosal defects. The median closure time was 12.5 (10–24) min, and the success rate of this procedure was 100%. Our CSC method was able to be performed in any part of the colon. In conclusion, the CSC method using a detachable snare in combination with the ZEOCLIP is a simple but promising closure technique for ESD‐induced mucosal defects. [ABSTRACT FROM AUTHOR]

Objectives: Although salvage endoscopic resection is an optimal treatment for local failure after chemoradiotherapy for esophageal squamous cell carcinoma, recurrent metastasis (lymph node and/or distant metastasis) after salvage endoscopic resection may occur with a certain degree of unavoidable frequency and is associated with a poor prognosis. However, the risk factors for recurrent metastasis are unclear. This study aimed to evaluate the risk factors for recurrent metastasis after salvage endoscopic resection. Methods: Patients who underwent salvage endoscopic resection for local failure after chemoradiotherapy/radiotherapy were analyzed in this single‐center, retrospective study. We evaluated the cumulative incidence rates of recurrent metastases, overall survival, and the risk factors for recurrent metastasis after salvage endoscopic resection. Results: We analyzed 132 patients. The 5‐year cumulative incidence rate of recurrent metastases after salvage endoscopic resection was 25.7%. The 5‐year overall survival rates in all patients and in patients with recurrent metastasis were 66.8% and 22.5%, respectively. Local failure pattern with a residual lesion after chemoradiotherapy/radiotherapy (subdistribution hazard ratio 2.34; P = 0.012) and the presence of lymphatic invasion in salvage endoscopic resection specimen (subdistribution hazard ratio 3.20; P = 0.002) were significant risk factors for recurrent metastasis. Conclusions: Patients with local failure pattern with a residual lesion after chemoradiotherapy/radiotherapy and presence of lymphatic invasion have a high risk for recurrent metastasis. Thus, appropriate surveillance for these patients should be considered. [ABSTRACT FROM AUTHOR]

Objectives: Advances in endoscopic technology, including magnifying and image‐enhanced techniques, have been attracting increasing attention for the optical characterization of colorectal lesions. These techniques are being implemented into clinical practice as cost‐effective and real‐time approaches. Additionally, with the recent progress in endoscopic interventions, endoscopic resection is gaining acceptance as a treatment option in patients with ulcerative colitis (UC). Therefore, accurate preoperative characterization of lesions is now required. However, lesion characterization in patients with UC may be difficult because UC is often affected by inflammation, and it may be characterized by a distinct "bottom‐up" growth pattern, and even expert endoscopists have relatively little experience with such cases. In this systematic review, we assessed the current status and limitations of the use of optical characterization of lesions in patients with UC. Methods: A literature search of online databases (MEDLINE via PubMed and CENTRAL via the Cochrane Library) was performed from 1 January 2000 to 30 November 2021. Results: The database search initially identified 748 unique articles. Finally, 25 studies were included in the systematic review: 23 focused on differentiation of neoplasia from non‐neoplasia, one focused on differentiation of UC‐associated neoplasia from sporadic neoplasia, and one focused on differentiation of low‐grade dysplasia from high‐grade dysplasia and cancer. Conclusions: Optical characterization of neoplasia in patients with UC, even using advanced endoscopic technology, is still challenging and several issues remain to be addressed. We believe that the information revealed in this review will encourage researchers to commit to the improvement of optical diagnostics for UC‐associated lesions. [ABSTRACT FROM AUTHOR]

Watch a video of this article. [ABSTRACT FROM AUTHOR]

Watch a video of this article. [ABSTRACT FROM AUTHOR]

The article discusses the use of endoscopic ultrasound (EUS) for diagnosing subepithelial lesions (SELs) and determining the management of gastrointestinal cancer. EUS-guided fine needle aspiration (EUS-FNA) is commonly used to obtain tissue samples from SELs, but the diagnostic yield is lower compared to pancreatic solid tumors. The article also mentions the development of minimally invasive treatments for SELs, such as endoscopic resection (ER), but highlights the challenges associated with these treatments. The study presented in the article evaluates an application system called SELERP for determining the management of SELs, and while the diagnostic results are somewhat inferior to previous studies, the application shows promise for predicting diagnosis and ER-related outcomes. The article concludes by emphasizing the importance of human training in performing EUS and making treatment decisions, despite the advancements in computer-aided diagnosis. [Extracted from the article]

Endoscopic management for perihilar cholangiocarcinoma (PHCC) is evolving toward more accurate diagnosis and safer drainage. In imaging, it is important to diagnose the entire lesion using multidetector‐row computed tomography to determine resectability and optimal surgical planning, followed by local diagnosis using endoscopic retrograde cholangiopancreatography. Video peroral cholangioscopy and probe‐based confocal laser endomicroscopy have been newly introduced as diagnostic imaging methods and are being applied clinically. In transpapillary forceps biopsy for PHCC diagnosis, the location in the bile duct (for mapping biopsy) and the number of biopsy samples should be determined depending on resectability, the morphological type, and future surgical planning. Preoperative drainage has shifted from percutaneous transhepatic biliary drainage to endoscopic nasobiliary drainage given the possibility of seeding metastasis. In addition, considering potential patient discomfort from a nasal tube, the usefulness of the placement of a plastic stent above the papilla (inside stent) as a bridging therapy for surgery has been reported. For drainage of unresectable PHCC, the improved prognosis due to advances in chemotherapy has necessitated a strategy that accounts for reintervention. Thus, in addition to uncovered self‐expandable metallic stents (SEMS), exchangeable slim fully covered SEMS and inside stents have started to be used. In addition to the conventional transpapillary approach, an endoscopic ultrasonography‐guided approach has been introduced, and a combination of both methods has also been proposed. To improve the quality of life and prognosis of PHCC patients, endoscopists need to understand and be able to use the various methods of endoscopic management for PHCC. [ABSTRACT FROM AUTHOR]

Endoscopic population‐based screening for gastric cancer began in April 2016, and the use of transnasal ultrathin esophagogastroduodenoscopy (UT‐EGD) has rapidly become popular. With UT‐EGD, discomfort associated with an examination is reduced, patient satisfaction is high, and adverse effects on cardiopulmonary function are fewer. Consequently, UT‐EGD is a good option for gastric screening in an aging society. Because of the narrower diameter of the endoscope, however, image quality is inferior to that obtained using transoral conventional esophagogastroduodenoscopy (C‐EGD). As a result, lesions observed by UT‐EGD must be viewed at close proximity and chromoendoscopy should be used concurrently, which is burdensome for the endoscopist. Recent innovations by endoscope manufacturers have enabled dramatic improvements in transnasal UT‐EGD and facilitated Hi‐Vision imaging. Furthermore, image enhancement that allows for observation on a par with transoral C‐EGD is now feasible. In the future, UT‐EGD will be equipped with functions that permit magnified endoscopic image. It is anticipated that a multiroute transition between transnasal and transoral UT‐EGD will become possible. [ABSTRACT FROM AUTHOR]

Objectives: Disconnected pancreatic duct syndrome (DPDS) is the most common cause of pancreatic fluid collection (PFC) recurrence. While long‐term transmural drainage with plastic stents is the preferred endoscopic approach, there is a paucity of literature on patients undergoing initial drainage with lumen‐apposing metal stents (LAMS). We describe our experience managing patients with DPDS. Methods: A retrospective review of a prospectively maintained database (November 2015–September 2020) was performed looking at clinical outcomes and overall survival for patients undergoing endoscopic management of PFCs using LAMS. The primary outcome was to assess recurrence‐free survival in PFC patients with DPDS managed with or without double pigtail stents (DPS) replacement after LAMS removal. Results: Of 96 patients with PFCs, 48 with DPDS were included in the study. The median follow‐up was 20.1 months. LAMS replacement with DPS was successful in 21/48 (43.8%) patients. Recurrence was seen in 1/21 (5%) patients with DPS replacement and 10/27 (37%) without DPS replacement. In multivariable models, a longer duration of LAMS placement was negatively associated with successful DPS replacement (odds ratio 1.33, 95% confidence interval [CI] 1.11, 1.59, P = 0.0019) and successful LAMS replacement with DPS in patients with DPDS improved recurrence‐free survival (hazard ratio 0.09, 95% CI 0.01, 0.83, P = 0.033). Conclusion: In patients with PFCs and DPDS, early replacement of LAMS with DPS improves the likelihood of successful long‐term transmural drainage and decreases recurrences. [ABSTRACT FROM AUTHOR]

Cover image: First image: The upper endoscopy revealed a Hill's flap grade III hiatal hernia; Second image: A partial mucosal resection (1/3 of circumference) with endoscopic mucosal resection with cap technique was performed along the lesser curvature of the cardia; Third image: The closure of the defect was achieved by the Loop‐9 closure technique, which involves an endoscopic purse‐string suturing method. (See Inoue H et al. p. 693–694).. [Extracted from the article]

The article discusses the use of the cold snare technique with clipping as a promising alternative treatment for duodenal angioectasia, a condition characterized by abnormal blood vessels in the mucosal and submucosal layers of the duodenum. The traditional treatment, argon plasma coagulation, carries risks such as pneumoperitoneum and perforation, making the need for safer options crucial. The article presents a case study of a 77-year-old woman with obscure gastrointestinal bleeding, where the cold snare technique effectively controlled bleeding and facilitated lesion removal without complications. The authors emphasize the importance of considering anatomical features in devising treatment strategies and commend the authors of the original article for contributing to the knowledge in this area. [Extracted from the article]

To overcome difficulties in the removal of duodenal bulb lesions, especially those in anatomically challenging locations, we developed the endoscopic resection via antral submucosal tunneling (ERAST) technique. In this study, we evaluated the feasibility and safety of ERAST for the removal of superficial and subepithelial lesions in the duodenal bulb. This was a single‐center retrospective study of 10 patients with lesions in the bulb. Submucosal tunneling from the gastric antrum to the duodenum was performed to facilitate en bloc tumor resection in the bulb. The en bloc resection rate, postoperative bleeding, and perforation were the primary endpoints. Ten lesions (four superficial and six subepithelial), with an average size of 19.1 ± 9.2 mm, were resected en bloc by ERAST. Esophagogastroduodenoscopy follow‐up after 2 months indicated complete wound healing in all patients. In our primary experience, ERAST was found to be a feasible and safe endoscopic resection technique for the removal of lesions in the duodenal bulb, especially those that are difficult to access. [ABSTRACT FROM AUTHOR]

With the prevalence of endoscopic submucosal dissection and endoscopic full thickness resection, which enable complete resection of T1 colorectal cancer with a negative margin, the treatment strategy following endoscopic resection has become more important. The necessity of secondary surgical resection is determined on the basis of the risk of lymph node metastasis according to the histopathological findings of resected specimens because ~10% of T1 colorectal cancer cases have lymph node metastasis. The current Japanese treatment guidelines state four risk factors for lymph node metastasis: lymphovascular invasion, histological differentiation, depth of submucosal invasion, and tumor budding. These guidelines have succeeded in stratifying the low‐risk group for lymph node metastasis, in which endoscopic resection alone is acceptable for cure. On the other hand, there are some problems: there is variation in diagnosis methods and low interobserver agreement for each pathological factor and 90% of surgical resections are unnecessary, with lymph node metastasis negativity. To ensure patients with T1 colorectal cancer receive more appropriate treatment, these problems should be addressed. In this systematic review, we gave some suggestions to these practical issues of four pathological factors as predictors. [ABSTRACT FROM AUTHOR]