BACKGROUND:Therapeutic endoscopic ultrasound (TEUS) has expanded into a broad procedural platform including access, delivery, measurement, ablation, drainage, and anastomoses. Nevertheless, TEUS lacks a shared procedural complexity classification. METHODS:Within an International initiative of the Next Generation EUS group, a dedicated task force developed a four-level classification, subsequently evaluated through Delphi methodology. The classification considered target stability and size, accessory exchange, adverse event profile, technical standardization, and prerequisite skills. To support and contextualize the consensus output, a targeted narrative review of published evidence was performed, analyzing technical success, clinical success, adverse events, learning curves, and procedural modifiers across major TEUS procedures. RESULTS:The Delphi-informed classification achieved 92.7% agreement among 106 respondents. Level 1 includes procedures mainly based on endosonographic skills, such as EUS-guided ablation and placement of Lumen Apposing Metal Stents (LAMS) within large fluid collections; Level 2 includes EUS-guided choledochoduodenostomy and gallbladder drainage with LAMS and fluid collection drainage with multistep plastic stenting; Level 3 includes more demanding fluoroscopy-based interventions, such as EUS-guided hepaticogastrostomy, rendezvous, and upper gastrointestinal anastomoses; Level 4 includes procedures with advanced complexity and limited standardization, such as EUS-directed ERCP, pancreatic duct drainage, and small/large bowel anastomoses. This article discusses the rationale, clinical utility, and training implications of this classification. CONCLUSIONS:This 4-level Delphi-informed classification for TEUS complexity achieved high expert agreement and provides a pragmatic framework to support training pathways, case selection, outcome interpretation, referral, and credentialing processes.
OBJECTIVES:Colonic spasm is one of the major technical challenges encountered during colonic endoscopic submucosal dissection (ESD), impairing visualization of the dissection plane and scope maneuverability. Submucosal lidocaine injection may help to overcome this challenge. This study aimed to evaluate the efficacy and safety of submucosal lidocaine injection during colonic ESD. METHODS:In this single-center, double-blind, randomized controlled trial, 110 patients scheduled for colonic ESD were randomly assigned to the lidocaine or control group. In the lidocaine group, 1% lidocaine with 0.6% sodium alginate was used for submucosal injection; in the control group, saline with 0.6% sodium alginate was used. The primary outcome was procedure time. Secondary outcomes included en bloc and R0 resection rates, incidence of severe spasms, number of antispasmodic administrations, operator satisfaction, and adverse events. RESULTS:The median procedure time was numerically shorter in the lidocaine group but did not reach statistical significance (67.5 vs. 78.0 min, p = 0.114). The en bloc and R0 resection rates were 100% and 84.6% in the lidocaine group, and 96.3% and 81.5% in the control group, respectively. Severe spasms occurred less frequently in the lidocaine group (34.6% vs. 74.1%), with fewer antispasmodic administrations (median, 1 vs. 2) and higher operator satisfaction scores (median, 4.0 vs. 2.5). No increase in adverse events was observed. CONCLUSIONS:Submucosal lidocaine injection did not significantly shorten procedure time, although it may serve as a useful adjunct for preventing colonic spasms during ESD. TRIAL REGISTRATION:The study was registered in the Japan Registry of Clinical Trials (jRCT1051230189).
Population aging has substantially altered the epidemiology and management of gastric cancer, particularly in East Asia, where a growing proportion of patients with early gastric cancer (EGC) are elderly. Current Japanese guidelines define indications and curability criteria for endoscopic resection (ER) irrespective of age. Consequently, gastrectomy with lymphadenectomy remains the standard treatment for EGC that exceeds established absolute and expanded ER indications or is classified as endoscopic curability (eCura) C-2 after ER. However, given the heterogeneity of metastatic risk and patient characteristics, uniform recommendation of gastrectomy may result in overtreatment in elderly patients. Nationwide registry data on patients undergoing gastrectomy have demonstrated that overall prognosis becomes increasingly limited and postoperative mortality rises with age, especially in men aged ≥ 75 years and women aged ≥ 80 years. These findings highlight the need to reconsider ER indications and post-resection management in elderly patients based on estimated lymph node metastasis (LNM) risk, operative mortality, and life expectancy. Recent studies suggest that expanding ER indications and redefining curability criteria in elderly patients using a higher acceptable LNM risk threshold, such as 10%, may represent a rational risk-adapted strategy. This concept is currently being evaluated in the multicenter phase III confirmatory trial conducted by the Japan Clinical Oncology Group (JCOG1902). Importantly, long-term outcomes in elderly patients with EGC are influenced by non-gastric cancer deaths. Therefore, management strategies should integrate tumor-related risk with patient-related factors, including comorbidities, nutritional status, frailty, and competing mortality risks, to achieve individualized and clinically meaningful care in this expanding population.
OBJECTIVES:Esophagogastroduodenoscopy (EGD) is useful for early detection of gastric cancer; however, quality indicators for its performance remain unestablished. We aimed to investigate the candidate quality indicators for EGDs conducted in patients undergoing surveillance following endoscopic submucosal dissection (ESD) for gastric neoplasms. METHODS:This study is a single-center, retrospective, observational analysis. We analyzed data from post-ESD surveillance EGDs between April 2015 and March 2022. The data were divided into Periods A (April 2015-March 2017) and B (April 2017-March 2022). From Period A, we calculated each endoscopist's gastric biopsy rate (gBR), gastric positive biopsy rate (gPBR), and mean examination time as potential quality indicators for EGD performance. In Period B, we calculated the gastric neoplasm detection rate, encompassing cancer and adenoma, as the primary outcome measure. We analyzed the associations between endoscopist quality indicators in Period A and clinical outcomes in Period B. RESULTS:A total of 6792 EGDs from 2552 patients, conducted by 12 endoscopists, were analyzed. A positive correlation with gastric neoplasm detection rate was observed for gBR (r = 0.621, p = 0.03), but not for the other indicators. Endoscopists with a high gBR (> 36%) had a significantly higher gastric neoplasm detection rate than those with a lower gBR (≤ 30%) (3.6% vs. 2.0%, p < 0.05). CONCLUSIONS:A higher gBR was associated with an increased gastric neoplasm detection rate in patients undergoing post-ESD surveillance. This finding suggests the potential of gBR as a quality indicator for EGD performance in this setting.
OBJECTIVES:Gastrointestinal foreign body ingestion or insertion can be an act of intentional self-harm. We aimed to provide a large-scale assessment of this clinical scenario. METHODS:This is a retrospective cross-sectional analysis of adult patients who presented with gastrointestinal foreign bodies and intent to self-harm. Hospitalizations were identified using the National Inpatient Sample from 2016 to 2023. Each hospitalization was characterized by the management methods used including no intervention, endoscopy, and surgery. Evaluated outcomes included ICU-level care, length of stay, and cost. Additionally, we assessed factors associated with the need for surgery after endoscopy. RESULTS:A total of 16,150 hospitalizations were identified. The mean age was 33.9 years and most patients were male (65.7%). Over one-third (35.2%) of patients had a cluster B personality disorder while 39.3% had schizophrenia and 24.2% were incarcerated. The majority (61.2%) of patients were managed with endoscopy alone while 26.4% required no intervention and 12.3% required surgery. ICU-level care was increased in those who required surgery, but the difference was not statistically significant (4.5% vs. 3.0%; OR 1.54, 95% CI: 0.91-2.62, p = 0.111). Small bowel location was associated with the need for surgery after endoscopy (aOR 2.50, 95% CI 1.91-3.28; p < 0.001). Over 12,000 hospital days and $25,000,000 were attributable to self-harm-associated gastrointestinal foreign bodies annually. DISCUSSION:Self-harm-associated gastrointestinal foreign bodies occur predominantly in patients with significant psychiatric comorbidity. Although mortality and severe morbidity are uncommon, healthcare utilization is substantial. Small bowel location is a key predictor of the need for surgical intervention.
