Background and Aims: Malignant gastric outlet obstruction (GOO) is an exceptionally rare and devastating condition in children, for which evidence-based management strategies are lacking. Although recent European guidelines endorse EUS-guided gastroenterostomy (EUS-GE) as an alternative to endoscopic stent placement and surgical gastroenterostomy in adults, its use in pediatrics is virtually unreported, to our knowledge. This absence of data leaves clinicians facing complex decision-making in profoundly challenging circumstances. We report on a pediatric case to illustrate the technical feasibility and potential clinical role of EUS-GE in malignant GOO. Methods: We describe stent placement during EUS-GE using the wireless EUS-GE simplified technique (WEST) in a 3-year-old boy with malignant GOO caused by recurrent abdominal neuroblastoma. Results: The procedure was technically and clinically successful, permitting resumption of oral intake and durable symptom control. The patient died 2 months later during palliative chemotherapy, without recurrence of GOO. Conclusions: This case highlights EUS-GE as a feasible palliative option for malignant GOO in highly selected pediatric patients. Given the rarity and severity of this condition, EUS-GE may be considered in expert centers with substantial experience in therapeutic EUS, underscoring the need for further reporting to inform future pediatric practice.
Background and Aims Iatrogenic esophageal perforation is a serious adverse event of therapeutic endoscopy and may require prompt closure. We report successful endoscopic closure of a large iatrogenic esophageal perforation using the Zigzag clip-with-line-pulley suturing (CLiPS) method. Methods An 84-year-old man with cirrhosis developed a 50-mm longitudinal esophageal perforation during endoscopic treatment of esophageal varices. Endoscopic closure was performed using the Zigzag CLiPS method, in which clips grasping a nylon thread were placed alternately along both edges of the defect. The defect was approximated by pulling the thread and secured with a detachable snare. Results Complete closure was achieved using 21 clips. Post-closure CT showed localized mediastinal air without abscess. The patient was managed conservatively with antibiotics and fasting. Endoscopy on day 7 confirmed intact closure, and oral intake was resumed. Follow-up endoscopy on day 41 showed sustained closure and progressive mucosal healing. Conclusions The Zigzag CLiPS method enabled successful endoscopic closure and conservative management of a large iatrogenic esophageal perforation and may be a practical option for selected gastrointestinal perforations.
Background and Aims Endoscopic transgastrostomal placement of a gastrojejunostomy (GJ) tube through an existing gastrostomy tract has a high technical rate of success for a procedure that can otherwise be challenging. This video demonstrates a standardized technique for transgastrostomal GJ tube placement using an ultrathin endoscope with endoscopic guidance. Methods We demonstrate a stepwise technique using an ultrathin gastroscope introduced directly through a mature gastrostomy tract to access the jejunum and place a stiff guidewire under direct visualization. A single-piece GJ tube is then advanced over the wire through the gastrostomy tract. A standard oral gastroscope is used to monitor tube advancement, prevent gastric looping, and facilitate pyloric passage using grasping forceps assistance when needed. Key technical considerations, troubleshooting strategies, and equipment selection are highlighted. Results The technique allows reliable jejunal guidewire placement and advancement of a single-piece GJ tube. Fluoroscopic placement can often fail when the gastrostomy tract does not face the pylorus. Direct visualization during all procedural stages overcomes this challenge, prevents intragastric looping, and allows for visual confirmation of final tube positioning. The procedure can be performed at the bedside or in the endoscopy suite. Published literature demonstrates high technical success and no major adverse events using similar transgastric endoscopic techniques. Conclusions Transgastrostomal gastrojejunostomy tube placement using an ultrathin endoscope is a safe and reproducible technique for patients with an existing mature gastrostomy tract requiring post-pyloric enteral access. This instructional video provides a standardized, step-by-step demonstration of the procedure, including equipment selection, procedural workflow, and troubleshooting strategies to facilitate implementation in clinical practice.
Background and Aims We present a case where an esophageal leak was initially managed with EndoVAC closure resulting in a cavity still large enough that primary closure would risk abscess formation. While continued EndoVAC treatment may eventually shrink the cavity, this would require prolonging the patient’s length of stay. We utilized an alternative technique of cavity closure over a pigtail stent to mitigate the risk of abscess formation. Methods During EndoVAC treatment, the patient was kept NPO and fed by GJ-tube. After three rounds of EndoVAC exchange at 5-day intervals, we placed a 7Fr double pigtail stent in the cavity and closed the cavity around it using the overstitch system. Results The patient’s diet was advanced and discharged on a full liquid diet, which was advanced to a soft diet outpatient that she tolerated well. A follow-up CT demonstrated no leak and that the pigtail had spontaneously passed. Conclusions Primary endoscopic closure of a residual perforation cavity over a pigtail may allow closure of large cavities by mitigating risk of abscess formation. This approach represents an endoscopic analog to the common surgical practice of managing dead space by prophylactic drain placement.
Background and Aims To introduce and evaluate a new endoscopic nasojejunal feeding tube insertion method. In 2010, we attempted to insert an elemental diet tube (ED) using an endoscope at the bedside of a patient in whom blind nasogastric tube insertion was impossible. This process unexpectedly led to jejunal feeding tube insertion (JFI), and endoscopic insertion was subsequently performed at the bedside in patients with aspiration, those at risk of aspiration, or those in whom blind ED insertion was difficult. As most patients underwent jejunal insertion, this study was initiated based on the belief that JFI would be possible by maximally inserting the ED using this method. Methods Success rates and problems associated with the JFI method were evaluated. Multiple silk threads were tied to the ED, which was positioned in the pylorus using an endoscope. The thread was grasped using endoscopic forceps to push the ED. When the grasping portion reached the pylorus, the oral-side thread was grasped and pushed, which continued reciprocally until the full length could be inserted, or the ED stopped advancing. Results Between 2011 and 2024, 97 insertions were performed at our hospital using this insertion method (92 jejunal and 5 duodenal insertions). All procedures were performed at the bedside, and most were performed easily. In a small number of patients, insertion was challenging owing to friction in the esophagus, requiring a switch to a slim endoscope or the use of an improvised handmade sheath. Conclusions The ED insertion method is effective and practical. For further improvement, the development of a dedicated sheath and improvements in tube properties are desirable.
Background and Aims Chronic marginal ulcers after Roux-en-Y gastric bypass (RYGB) are a challenging adverse event that can remain refractory to traditional medical therapy. We describe a novel regenerative endoscopic approach using an acellular dermal matrix (ADM) secured with a lumen-apposing metal stent (LAMS) to heal a non-healing 3-cm gastrojejunal (GJ) ulcer. Methods A 57-year-old woman with a history of RYGB presented with chronic, piercing epigastric pain and syncope secondary to a recurrent marginal ulcer. Endoscopy revealed a 3-cm cratered ulcer at the GJ anastomosis. Treatment involved thermal preparation with argon plasma coagulation (APC), followed by the placement of a human ADM allograft transported via a retrieval net. The graft was secured with hemostatic clips and a 20 x 10 mm LAMS was deployed to ensure sustained apposition. Results Successful graft incorporation was observed during stent removal at four weeks. Surveillance endoscopy at three months confirmed complete resolution of the stomal ulceration and healthy mucosal coverage at the previous defect site. Conclusions Regenerative endoscopy using biological scaffolds like ADM offers a viable strategy for managing previously intractable internal mucosal defects by providing a framework for host tissue repair.
Background and Aims Management of large gastric neuroendocrine tumors (g-NETs) can be challenging, particularly in patients with substantial comorbidities. Conventional therapies, including endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and surgery, may carry prohibitive procedural risk or require prolonged operative time in such patients. We describe the use of endoscopic ultrasound-guided microwave ablation (EUS-MWA) as a local therapeutic option for a bleeding g-NET. Methods A 73-year-old woman with cirrhosis and recent transcarotid artery revascularization (TCAR), requiring dual antiplatelet therapy, presented with melena and acute-on-chronic anemia secondary to an ulcerated gastric cardia NET. EUS-guided microwave ablation was performed using a 19-gauge EUS-MWA needle antenna and a 2.45-GHz generator. Eight 1-minute ablation cycles were delivered under real-time EUS guidance using a fan-and-withdraw technique. Results Successful ablation was demonstrated intraprocedurally by the appearance of a hyperechoic “snowstorm” pattern and post-ablation tissue desiccation. The patient’s hemoglobin subsequently normalized to 12.9 g/dL without need for further intervention. Surveillance endoscopy at 3 months demonstrated a well-healed 5-mm scar without residual mucosal lesion or sonographic evidence of recurrence. Conclusions EUS-guided microwave ablation may represent a feasible and effective local treatment option for symptomatic gastric neuroendocrine tumors, particularly in patients in whom conventional endoscopic or surgical therapies are high risk or not feasible.
Background and Aims Stricture formation is a significant delayed adverse event following colorectal Endoscopic Submucosal Dissection (ESD). Post-ESD strictures may respond poorly to conventional Endoscopic Balloon Dilation (EBD). We developed a novel technique, Stricturotomy-then-Dilation (StD), which involves same-session endoscopic stricturotomy and EBD for the treatment of post-ESD rectal strictures. Methods A retrospective analysis of a prospectively maintained registry from November 2019 to December 2025 was performed. Patients with symptomatic post-endoscopic submucosal dissection rectal strictures refractory to EBD, defined as persistent symptomatic stenosis despite at least two prior EBD sessions, were included. Primary outcome was clinical success considered as lumen diameter ≥12mm and symptom resolution. Secondary outcomes included: technical success, adverse events and recurrence rate. Results Among 187 patients who underwent rectal ESD, 16 (8.5%) had resections involving ≥90% of the circumference. Overall, 15 patients (8.0%) developed stenosis, and 7 of these (3.7%) progressed to refractory strictures. After StD treatment (median 2 sessions), all patients achieved technical and clinical success (100%). No adverse events occurred, and no symptomatic recurrences were observed during median follow-up of 493 days (IQR 229). Conclusions These preliminary findings support the feasibility of StD for post-ESD rectal strictures refractory to conventional EBD. Confirmation in larger, prospective cohorts is needed.
Background and Aims Angiomyolipoma (AML) is a benign mesenchymal tumor, commonly renal, with pancreatic localization being exceptionally rare. While renal AMLs are usually monitored unless symptomatic or high-risk, no standardized management exists for pancreatic AMLs. We report a case of a 34-year-old man with abdominal pain and a fat-containing lesion in the pancreatic head. Methods Abdominal MRI (magnetic resonance imaging) showed a 2.2 x 2 cm fat-containing mass in the pancreatic head with nodular enhancement on delayed post-contrast images. Endoscopic ultrasound (EUS) revealed a well-defined, hyperechoic lesion with peripheral vascularity. EUS-guided fine-needle biopsy (FNB) confirmed AML. Results Considering the lesion’s size, symptoms, location, and malignancy-related anxiety, a shared decision was made to proceed with EUS-guided radiofrequency ablation (RFA). Five RFA applications (30 watts, 6–10 seconds each) were delivered transgastrically without complications. At one-month follow-up, the patient was asymptomatic, and imaging showed lesion reduction with features suggestive of necrosis. Conclusions EUS-guided RFA may offer a safe, minimally invasive, and organ-preserving therapeutic approach for pancreatic AML. This case also highlights the need to consider AML in the differential diagnosis of pancreatic masses.
Background and Aims Endoscopic self-expandable metal stent (SEMS) placement is established for malignant gastroduodenal obstruction, whereas its use in jejunal strictures has been rarely reported because of the technical challenges associated with small bowel anatomy. We describe a case in which stepwise placement of multiple duodenal SEMS treated multifocal jejunal strictures due to peritoneal dissemination. Methods A 62-year-old woman with advanced breast cancer and peritoneal dissemination presented with recurrent intestinal obstruction. Contrast study demonstrated multifocal stenoses involving the duodenum and jejunum, including a long jejunal stricture measuring approximately 15 cm. Endoscopic placement of multiple duodenal SEMS was performed across the duodenal and jejunal strictures, achieving sufficient luminal patency from the duodenum to the jejunum. Results After stent placement, obstructive symptoms improved. Oral intake was resumed 3 days after the procedure, allowing early discharge. The patient remained free from stent dysfunction for 5 months until transition to best supportive care. Conclusions Stepwise placement of multiple duodenal SEMS may represent a safe and effective palliative option for multifocal jejunal strictures secondary to peritoneal dissemination, enabling symptom relief and resumption of oral intake, although further studies are needed.
Background and Aims Cholangioscopy-guided lithotripsy through an endoscopic ultrasound–guided hepaticojejunostomy (EUS-HJS) tract is challenging as the working space is constrained and angulation may compromise probe control. We compared a slim and a larger cholangioscope on the same platform using repeated bench-top measurements and assessed clinical applicability. Methods The EHL probe was advanced until the distal tip first became visible; scope-tip–to–distal-tip visibility distance was measured with a 0.1-mm caliper at 0° and 20° up-angulation (90° assessed only if feasible). As a stability surrogate, center-to-tip deviation was measured at a fixed 4-mm protrusion. Measurements were repeated by two operators and summarized as mean ± SD. Results The slim scope showed shorter visibility distance and maintained feasibility under high angulation. An 80-year-old man with Roux-en-Y reconstruction underwent EUS-HJS after failed transpapillary access. Subsequent cholangioscopy-guided EHL and retrieval-balloon extraction via the HJS tract achieved complete stone clearance without adverse events; no recurrence occurred at 1-year follow-up. Conclusions In a constrained, angulated tract, scope selection should prioritize the feasibility and controllability of probe advancement over fragmentation efficiency, which may otherwise favor a larger scope with a larger-caliber probe.
Background and Aims Submucosal tunneling endoscopic resection (STER) represent a minimally invasive therapeutic technique for selected gastric gastrointestinal stromal tumors (GISTs). However, procedural success is highly dependent on lesion characteristics and technical execution. We present a structured approach to gastric GIST and a key technical consideration for successful STER by contrasting an unsuccessful and a successful case. Methods Two patients with gastric GISTs arising from the muscularis propria underwent attempted STER. Pre-procedural endoscopic ultrasound (EUS) was performed to assess lesion size, depth, and growth pattern. Procedural steps including tunnel strategy, scope orientation, and adjunctive maneuvers were analyzed to identify factors influencing technical success. Results In the first case, STER was performed with long tunnel, however; due to the exophytic nature of GIST resulted in failure to visualize it, leading to procedural abortion. In contrast, the second case demonstrated successful STER using a short tunnel approach, horizontal mucosal incision to facilitate specimen extraction, careful scope re-orientation to establish a tangential dissection plane, and snare-assisted confirmation of complete tumor mobilization. A mucosal tear occurred due to forward pressure during dissection and was managed with endoscopic suturing without adverse events. Conclusions Successful STER for gastric GISTs can result from meticulous pre-procedural EUS assessment, horizontal incision with short tunnel creation, and selective use of adjunctive techniques. Awareness of these technical principles may improve procedural success and safety.
Background and Aims:Endoscopic submucosal dissection (ESD) of lesions involving the ileocecal valve and terminal ileum is technically challenging. The saline-immersion technique for ESD combined with countertraction may improve visualization, safety, and dissection efficiency in these complex locations. Methods:A 71-year-old patient underwent ESD for a 4-cm nongranular flat adenoma involving the entire ileocecal valve and extending into the distal terminal ileum. The procedure was performed with the patient under general anesthesia using a pediatric colonoscope (PCF-H190TL; Olympus, Tokyo, Japan) with a tapered hood (ST Hood; Fujifilm, Tokyo, Japan). After chromoendoscopic margin delineation, the lumen was filled with saline solution, and submucosal dissection was completed under saline immersion using ENDO CUT current (Erbe VIO 3, Tübingen, Germany). Two clip-and-band complexes provided internal countertraction to improve exposure and facilitate controlled dissection. Results:En bloc resection, including the ileocecal valve and ileal extension, was achieved. Hemostasis was secured with hot biopsy forceps, and partial defect closure was performed with clips. The postoperative course was uneventful, and the patient was discharged after 48 hours. Oral budesonide was administered for 2 months to reduce the risk of stricture. At 3-month follow-up, the patient was asymptomatic without endoscopic recurrence. Conclusions:Under-saline solution ESD with clip-and-band traction appears safe and effective for extensive ileocecal lesions, providing stable visualization, reliable countertraction, and easy access to the submucosal space.
Background and Aims Circumferential adenoma of the duodenum is uncommon, and, due to its malignant potential, resection is often recommended based on the patient's clinical status. Mucosectomy of these lesions is a viable alternative to the Whipple procedure, and can be performed safely and with good results. However, extensive endoscopic resection of duodenal lesions entails a risk of late perforation. Methods We present the resection of a circumferential adenoma of the duodenum using the piecemeal endoscopic mucosal resection (pEMR) technique with subsequent cauterization of the lesion margins. Papillectomy and prophylactic pancreatic duct stent placement were also performed. Due to the extensive resection area, an endoluminal vacuum therapy (EVT) was used to prevent perforation and stenosis. Results The lesion was resected endoscopically with pEMR without perforation. One month after the procedure, four endoscopic balloon dilation (EBD) sessions were required to manage luminal stenosis, with symptomatic improvement. At the six-month follow-up, a residual polyp was observed and managed by cold snare resection and argon plasma ablation. Complete resolution was confirmed 19 months after the initial procedure. Conclusions Circumferential adenomas of the duodenum can be safely treated with endoscopic therapy with good results. Preemptive EVT in the perioperative period and EBD may be considered in therapeutic planning.
Background and Aims Pseudoaneurysms carry a significantly higher risk of rupture compared with true aneurysms, with reported mortality approaching 50%. Internal iliac artery pseudoaneurysms are rare and are traditionally managed by surgical or endovascular techniques. Endoscopic ultrasound (EUS)–guided coil and glue embolization is well established for gastric varices and visceral arterial aneurysms. We describe the feasibility of extending this approach via a transrectal EUS route for treatment of an internal iliac artery pseudoaneurysm. Methods A 61-year-old woman with cryptogenic chronic liver disease (Child–Pugh A) was incidentally found to have a 2-cm right internal iliac artery pseudoaneurysm on cross-sectional imaging. Given the high risk of rupture and limitations to endovascular therapy, transrectal EUS-guided embolization was performed using a linear echoendoscope under Doppler guidance. Coil followed by cyanoacrylate glue was deployed into the pseudoaneurysm sac until complete obliteration of flow was confirmed. Results Technical success was achieved with immediate cessation of Doppler flow. There were no intraprocedural or delayed complications. The patient remained asymptomatic at 2-week and 6-month follow-up. Conclusions Transrectal EUS-guided coil and glue embolization is a feasible and effective minimally invasive option for selected internal iliac artery pseudoaneurysms when conventional approaches are limited.
Background and Aims Biliary atresia is a congenital cause of neonatal obstructive jaundice. Although Kasai portoenterostomy remains the standard treatment, late complications such as cholangitis and intrahepatic stones may eventually lead to liver transplantation. Endoscopic treatment for intrahepatic stones in biliary atresia has rarely been described. Methods We developed a novel three-step endoscopic strategy for right intrahepatic stones in a woman with postoperative type III biliary atresia. Because the left intrahepatic duct was dilated and accessible under endoscopic ultrasound guidance, an endoscopic ultrasound-guided hepaticogastrostomy was created via B2. Second, peroral cholangioscopy (POCS) was used to explore and dilate the obstructed portoenterostomy tract toward the Roux limb. Third, balloon dilation enabled access to the right hepatic duct, allowing electrohydraulic lithotripsy (EHL) and stone extraction. Results This approach enabled complete endoscopic clearance of right intrahepatic stones in surgically altered anatomy. Treatment was completed in three separate sessions. No adverse events occurred, and the patient remained free of recurrent cholangitis and right intrahepatic stones during 1.5 years of follow-up. Conclusions This minimally invasive endoscopic technique may offer a treatment alternative in selected postoperative biliary atresia patients and reduce the need for liver transplantation.
Background and Aims: A 69-year-old male patient with a previous duodenal switch surgery presented with choledocholithiasis and cholangitis. Initially, interventional radiology (IR) performed biliary stent placement with a metal stent left in situ. One year later, the patient presented again with cholangitis, now requiring definitive treatment via EUS-directed transduodenal ERCP (EDDE). Methods: An anastomosis was created between the first portion (superior portion) of the duodenum (D1) and the excluded second portion (descending portion) of the duodenum (D2) using a lumen-apposing metal stent (LAMS). After anastomosis maturation, the patient returned for ERCP and removal of the IR-placed stent. The previously placed stent initially could not be removed, so a metal stent was placed within the IR-placed stent for later removal via stent-in-stent technique. Three months later, the stents were removed, and the bile duct was swept with a balloon. Stones and debris were extracted from the duct. The duodenoduodenal LAMS was removed, leaving a patent fistula in place. Results: An EDDE was successfully performed between the D1 and D2 portions of the duodenal switch. The patient was asymptomatic and stent-free. Conclusions: The successful completion of this procedure indicates that it may be safe and effective to perform an EDDE in patients with duodenal switch anatomy.
Background and Aims Ensuring an adequate vertical margin (VM) is critical in endoscopic resection (ER) for T1 colorectal cancer (CRC). We aimed to demonstrate a novel underwater-assisted hybrid endoscopic submucosal dissection (ESD) strategy to optimize deep submucosal capture and ensure an adequate VM. Methods We performed underwater-assisted hybrid ESD for a 20-mm Paris type 0-IIa+IIc cecal lesion suspected of deep T1 CRC. After circumferential mucosal incision and circumferential submucosal dissection, the lumen was filled with saline. Additional submucosal injection and snaring under underwater condition were then performed to facilitate deep submucosal capture using the buoyancy effect. Results The lesion was successfully resected en bloc without adverse events. Histopathology revealed pT1b adenocarcinoma with a submucosal invasion depth of 2300 μm, negative horizontal and vertical margins, and a VM distance of 1020 μm. Conclusions Underwater-assisted hybrid ESD may represent one possible ER strategy for ensuring an adequate VM for T1b CRC ≤30 mm. When pathological evaluation reveals pT1b CRC, additional surgical management should generally be considered through multidisciplinary assessment, given the potential risk of lymph node metastasis.
Background and Aims:EUS-guided hepaticogastrostomy (EUS-HG) is increasingly used to achieve internal biliary drainage in patients with altered anatomy or inaccessible papillae. However, failure may occur secondary to nondilated intrahepatic ducts that preclude guidewire passage, or the inability to dilate fibrotic tracts or advance a stent, especially in patients with cirrhosis. This video demonstrates the use of rendezvous techniques to rescue failed EUS-HG and enable successful internal drainage. Methods:Five patients who failed conventional EUS-HG underwent rescue with 1 of 3 techniques: EUS-to-interventional radiology (IR) rendezvous using an IR-inflated target balloon (n = 3), IR-to-IR rendezvous using dual percutaneous access and transhepatic puncture through a snare (n = 1), and endoscopic rendezvous using oral wire retrieval and retrograde dilation (n = 1). Fully covered metal stents were deployed in all cases. Results:Technical success was achieved in all 5 patients. One patient did not achieve complete clinical resolution because of persistent hepaticojejunostomy dehiscence. No adverse events occurred during or after the procedure. The median follow-up was 28 months. Conclusions:EUS-guided rendezvous-hepaticogastrostomy offers an effective and safe solution for salvaging failed EUS-HG. These techniques should be considered before defaulting to long-term percutaneous biliary drainage.
