Objectives:Adequate pharyngeal observation during esophagogastroduodenoscopy (EGD) is increasingly recognized as an important component of high-quality upper gastrointestinal endoscopy. However, visualization may be impaired by gag reflexes and patient movement. The current study evaluated the association between sedation strategy and successful pharyngeal observation during routine EGD. Further, whether this association differs according to operator experience was examined. Methods:This retrospective single-center observational study included consecutive sedated EGD procedures performed between April 2024 and March 2025. Successful pharyngeal observation was defined as the successful identification of predefined pharyngeal and hypopharyngeal anatomical landmarks. Multivariate logistic regression analysis was performed to identify factors independently associated with successful pharyngeal observation. Interaction, sensitivity, and propensity score-matched analyses were also conducted. Results:In total, 444 EGD procedures, including 245 performed under midazolam sedation and 199 under propofol sedation, were analyzed. The propofol group had a significantly higher successful pharyngeal observation rate than the midazolam group (90.0% vs. 79.2%, p = 0.011). In the multivariate analysis, propofol sedation was independently associated with successful pharyngeal observation (odds ratio: 2.18, 95% confidence interval: 1.20-3.96, p = 0.008). Sensitivity analyses excluding biopsy cases and analyses restricted to trainees yielded consistent results. Propensity score-matched analysis also yielded consistent results. Conclusions:Sedation strategy was independently associated with successful pharyngeal observation during routine EGD. Propofol sedation may facilitate a more consistent pharyngeal visualization across operators with varying levels of experience. Trial Registration:N/A.
Duodenal laparoscopy and endoscopy cooperative surgery (D-LECS) for superficial non-ampullary duodenal tumors has been increasingly performed as a minimally invasive treatment for lesions with a high risk of complications when treated by endoscopy alone. However, for tumors near the papilla of Vater, the optimal treatment strategy has not been established because of the risk of pancreatitis and cholangitis associated with papillary injury. We report a case of duodenal adenoma near the papilla of Vater successfully treated by D-LECS combined with endoscopic nasopancreatic drainage (ENPD) and endoscopic nasobiliary drainage (ENBD). A 70-year-old woman was found to have a 0-IIa adenoma adjacent to the papilla in the descending portion of the duodenum and underwent D-LECS with endoscopic retrograde cholangiopancreatography assistance. After Kocher mobilization, endoscopic en bloc resection was performed. The mucosal defect was closed using endoscopic mucosal closure and reinforced with laparoscopic seromuscular suturing. To prevent postoperative complications, ENPD and ENBD were performed. Pathological examination confirmed negative resection margins, and the patient was discharged with an uneventful postoperative course. ENPD and ENBD after D-LECS were technically feasible without interfering with endoscopic manipulation. This combined approach may be a selective organ-preserving strategy for carefully selected duodenal tumors located near the papilla of Vater.
Esophageal varices are a common complication of portal hypertension, and prophylactic endoscopic injection sclerotherapy with ligation (EISL) is an established treatment option. Effective variceal thrombosis requires sufficient intravariceal retention of the sclerosant, because ethanolamine oleate exerts its thrombogenic effect through prolonged contact with the venous endothelium. In conventional EISL, endoscopic variceal ligation (EVL) is performed after balloon deflation, leaving a transient interval during which restored blood flow and an open puncture site may permit washout of the sclerosant and bleeding. We describe EIS with pre-deflation ligation (EISpdL), in which EVL of the puncture site is completed while the endoscope balloon remains inflated, and balloon compression is maintained throughout the retention period. A 59-year-old man with medium-sized esophageal varices with a positive red color sign (F2, RC1) secondary to metabolic dysfunction-associated steatohepatitis underwent EISpdL combined with gel-immersion EIS. The procedure was technically feasible, required no additional skills beyond conventional EISL, and no immediate procedure-related adverse events were observed. Follow-up endoscopy on post-procedure day 7 showed bronze-colored variceal changes indicating thrombosis, and contrast-enhanced computed tomography two months later confirmed obliteration. EISpdL may enable more stable and prolonged sclerosant retention.
Objective:Covered self-expandable metal stents (SEMS) are widely used for treating distal malignant biliary obstruction (MBO). Severe SEMS angulation can cause stent dysfunction. Placement of a long double-pigtail plastic stent inside the SEMS (the "long-anchoring stent method") may straighten the angulated SEMS, thereby achieving effective biliary drainage. This study aimed to report the clinical outcomes of this novel method. Methods:We retrospectively analyzed 15 patients with distal MBO who underwent initial SEMS placement, subsequently experienced clinical failure or early recurrent biliary obstruction (RBO) within 90 days of initial placement, and underwent reintervention with the long-anchoring stent method between April 2020 and March 2025. Results:The median follow-up period was 307 days after the anchoring procedure. For the primary outcome, clinical success was achieved in all 5 patients with initial SEMS clinical failure and in all 15 patients overall. The median angle of the SEMS significantly straightened from 128.3° with the initial SEMS alone to 151.5° after anchoring stent placement (p < 0.001). As an exploratory analysis of the 10 patients with early RBO, the median time to RBO increased from 21 days after initial SEMS placement to 148 days after anchoring procedure. No severe procedure-related adverse events occurred. Conclusion:The long-anchoring stent method is a simple, safe, and viable strategy for rescuing early dysfunction of covered SEMS, possibly in part through straightening of the SEMS angulation. Trial Registration:N/A.
Angiosarcoma is a rare, aggressive vascular malignancy, and gastrointestinal involvement is uncommon. We report disseminated angiosarcoma with multifocal small-bowel involvement presenting as suspected small-bowel bleeding, in which small-bowel capsule endoscopy (SBCE) and double-balloon endoscopy (DBE) were diagnostically useful. A man in his 60s presented with recurrent melena and transfusion-dependent anemia. SBCE showed active jejunal bleeding with multiple ulcerative lesions, and antegrade DBE revealed hemorrhagic tumors with luminal narrowing. Retrograde DBE demonstrated additional ileal and colonic lesions. Computed tomography showed small-bowel stenosis, mesenteric dissemination, bone metastases, and soft-tissue infiltration around an abdominal aortic stent graft. The patient died 7 weeks after transfer. Autopsy confirmed disseminated angiosarcoma involving the small intestine and mesentery, with the greatest tumor burden around the aortic graft, suggesting a possible periaortic origin. This case highlights the complementary roles of SBCE and DBE and provides rare clinicopathological correlation with autopsy findings.
Objectives:Nasal high flow (NHF) improves oxygenation, reduces the work of breathing, and stabilizes ventilation. In endoscopic retrograde cholangiopancreatography (ERCP) under dexmedetomidine-based sedation, opioids are often required but increase the risk of respiratory depression and delayed recovery. This study tested the hypothesis that NHF therapy, compared with low-flow oxygen (LFO), may reduce opioid requirements during ERCP. Methods:This open-label, single-center, randomized controlled trial enrolled patients undergoing ERCP under dexmedetomidine-based sedation. Patients were randomized to NHF or LFO. Sedation used dexmedetomidine, midazolam and pethidine with a standardized protocol. The primary endpoint was total pethidine dose. Secondary endpoints included transcutaneous carbon dioxide (TcCO2), oxygenation-perfusion parameters, processed electroencephalography (EEG) parameters, sedative doses, and sedation depth. Results:Enrollment ended early at a total of 94 of the planned 118 patients due to slow recruitment (NHF 47, LFO 47). Poisson regression demonstrated reduced opioid requirements with NHF (incidence rate ratio 0.77, 95% confidence interval, 0.62-0.96, p = 0.023). The total pethidine dose was lower in the NHF group (medians 43.75 mg vs. 70.00 mg, p = 0.004). The TcCO2 and oxygenation-perfusion parameters were comparable between groups. EEG tests showed lower patient state index and electromyographic activity in the NHF group, indicating deeper sedation. No adverse events attributable to interventions were observed. Conclusion:NHF reduced opioid requirements while maintaining oxygenation, ventilation, and sedation during ERCP. The ability of NHF to provide respiratory support, ensure adequate oxygenation, and allow monitoring of breathing makes it a promising modality during procedural sedation; however, further multi-center studies are needed. Trial Registration:072210047 [jRCTs].
Objectives:Endoscopic sphincterotomy (EST) is a high-risk procedure with a steep learning curve. We previously developed a novel dry simulator capable of reproducing bleeding after an inappropriate incision. This study aimed to evaluate the effectiveness of a structured educational program using the simulator within the Bethesda Endoscopic retrograde cholangiopancreatography (ERCP) Skill Assessment Tool (BESAT) framework. Methods:This prospective study implemented a standardized training sequence: (1) preliminary video-based learning; (2) an initial attempt at cannulation, EST, and biliary stone extraction; (3) BESAT-based expert feedback focusing on six key technical tips; (4) a second attempt. The primary outcome was the change in EST success, which is defined by an incision in the 11-12 o'clock direction with appropriate length and no bleeding, before and after feedback. Secondary outcomes were procedure completion, including stone removal within 15 min, and subjective self-assessments of procedural understanding and confidence. Results:Thirty gastroenterology trainees were enrolled. The EST success rate increased from 43.3% to 76.7% (p < 0.05). The completion rate of the procedure tended to increase from 46.7% to 70.0% (p = 0.07). Subjective self-confidence improved from a median of 24.0-53.0 after training and remained at 53.5 at 3 months; other self-assessed domains also improved and were sustained. Post-hoc analysis showed that initial EST success was associated with >50 prior ERCP cases (odds ratio = 7.86, 95% confidence interval: 1.31-47.0, p < 0.05). Conclusions:A structured simulator-based program enables trainees to experience failure and improves simulator-based EST performance with sustained gains in self-efficacy. Trial Registration: The trial was prospectively registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000044823).
Background:Surgical fundoplication is the standard treatment for refractory gastroesophageal reflux disease (GERD) with large (≥3 cm) hiatal hernias; however, its invasiveness is problematic in older adults and high-risk patients. Anti-reflux mucosal intervention (ARMI) is a less invasive endoscopic alternative; however, patients with large hernias have previously been excluded from studies, limiting available evidence. We assessed the feasibility, short-term clinical outcomes, and safety of ARMI in this population. Methods:We retrospectively analyzed consecutive patients with proton pump inhibitor (PPI)/potassium-competitive acid blocker (P-CAB)-refractory GERD and sliding hiatal hernias ≥3 cm who underwent ARMI (anti-reflux mucosectomy; anti-reflux mucoplasty) between April 2024 and April 2025. GERD-Health-Related Quality of Life (GERD-HRQL), GERD Questionnaire (GerdQ), and Frequency Scale for the Symptoms of GERD (FSSG) scores were compared before ARMI and 3 months afterward. PPI/P-CAB discontinuation and treatment-related adverse events were also assessed. Results:Ten patients (mean age 74.3 years; 80% women; hernia size 3-6 cm) were included, all with American Society of Anesthesiologists physical status ≥ II. At 3 months, mean GERD-HRQL scores decreased from 21.1 to 4.6 (p = 0.002), FSSG from 22.6 to 6.2 (p = 0.004), and GerdQ from 10.9 to 4.6 (p = 0.008). PPI/P-CAB was discontinued in seven patients. No clinically significant treatment-related adverse events, including perforation, delayed bleeding, or dysphagia, occurred. Conclusions:ARMI was technically feasible, showed favorable short-term outcomes in patients with refractory GERD and 3-6-cm hiatal hernias, and may represent a less invasive option for older or high-risk patients. Trial Registration:N/A.
Background and Aims:Accurate histological differentiation between hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) is essential for selecting appropriate treatment. Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is increasingly used for focal liver lesions; however, comparative data on its diagnostic sensitivity for HCC and ICC remain limited. This study compared the diagnostic sensitivity of EUS-TA for these malignancies. Methods:This single-center retrospective study included patients who underwent EUS-TA for focal liver lesions and were ultimately diagnosed with HCC or ICC between 2016 and 2024. Patients with extrahepatic cholangiocarcinoma were excluded. The primary outcome was overall diagnostic sensitivity. Secondary outcomes were cytological sensitivity and procedure-related adverse events. Results:Forty-five patients were included (HCC, n = 18; ICC, n = 27). Median lesion size was 41 mm. Baseline characteristics were similar, except that fine-needle biopsy needles were used less frequently in HCC than in ICC (16.6% vs. 48.1%, p = 0.032). Overall diagnostic sensitivity was high in both groups but lower in HCC than in ICC (83.3% [95% confidence interval {CI}, 58.6-96.4%] vs. 100% [95% CI, 87.2%-100%], p = 0.029). The difference was more pronounced for cytological sensitivity (22.2% [95% CI, 6.4%-47.6%] vs. 77.8% [95% CI, 57.7%-91.4%], p = 0.0007). No procedure-related adverse events occurred. Conclusions:EUS-TA demonstrated high diagnostic sensitivity for both HCC and ICC without procedure-related adverse events. However, diagnostic sensitivity, particularly cytological sensitivity, was lower in HCC, consistent with the known pathological characteristics of HCC and the established role of histological evaluation in its diagnosis. Trial Registration: N/A.
Ingested toothpicks can perforate the gastrointestinal tract and penetrate adjacent organs. Pancreatic involvement is rare, and its management varies between surgical and endoscopic interventions. We report the successful endoscopic removal of a toothpick that penetrated the gastric wall and extended into the head of the pancreas. A 59-year-old man presented with a 5-day history of fever and epigastric pain. Laboratory tests revealed inflammatory changes, with normal serum amylase and hemoglobin levels. Non-contrast computed tomography (CT) with multiplanar reconstruction (MPR) revealed a linear, slightly hyperattenuating foreign body measuring at least 5 cm, extending from the posterior wall of the lower body of the stomach to the head of the pancreas, with minimal free air, surrounding fat stranding, and no dilation of the main pancreatic duct. Contrast-enhanced CT revealed no major vascular involvement or active extravasation. Esophagogastroduodenoscopy was performed on hospital day 3 with surgical backup. A wooden foreign body protruding from the gastric mucosa was removed with biopsy forceps through an overtube under conscious sedation. The extracted object was a 6.5-cm wooden toothpick. The post-procedural course was uneventful. This case highlights the value of MPR and contrast-enhanced CT in defining a foreign body's trajectory and determining procedural feasibility. Endoscopic removal may be a safe and minimally invasive alternative to surgery in selected cases of pancreatic penetration.
Traumatic neuroma of the cystic duct stump is a rare benign lesion that may mimic biliary malignancy, making preoperative diagnosis challenging. We report a case of an enhancing lesion at the cystic duct stump after cholecystectomy that was diagnosed by endoscopic ultrasound-guided tissue acquisition (EUS-TA). Imaging studies revealed an 8-mm enhancing nodule at the cystic duct stump, and endoscopic retrograde cholangiopancreatography showed a unilateral filling defect at the corresponding site. Peroral cholangioscopy demonstrated smooth mucosa without irregular vessels, suggesting a submucosal lesion rather than mucosal malignancy. EUS revealed a well-demarcated, homogeneous hypoechoic mass immediately distal to the origin of the remnant cystic duct. EUS-TA using a 22-gauge needle enabled TA from the lesion. Histopathological examination showed proliferation of spindle-shaped cells with wavy nuclei, and immunohistochemical staining was positive for S-100 protein, confirming the diagnosis of traumatic neuroma. No procedure-related adverse events occurred, and unnecessary surgical resection was avoided. EUS-TA may facilitate preoperative diagnosis of cystic duct stump traumatic neuroma and help guide appropriate management.
Objectives:Computer-aided detection (CADe) using deep learning is promising for reducing missed gastric cancers (MGCs) and supporting physicians in double-checking endoscopic images. We aimed to evaluate the CADe efficacy for MGCs after endoscopic submucosal dissection (ESD). Methods:We collected 2324 endoscopic images, including 60 of MGCs detected during surveillance esophagogastroduodenoscopy within 18 months after initial ESD. The performance of the CADe system, developed for early GC detection using deep learning, was compared with that of 10 endoscopists in a detection study using collected images. Per-lesion sensitivity, per-image detection performance, and diagnostic time were compared. Results:The per-lesion sensitivity for MGCs was 15.0% (9/60) and 13.8% (83/600) for CADe and endoscopist detection, respectively (p = 0.538). The respective per-image computer-aided and endoscopist performance sensitivity was 11.3% and 10.6% (p = 0.548), specificity 88.5% and 94.8% (p < 0.001), positive predictive value 4.4% and 8.3%, and negative predictive value 95.7% and 96.0%. The per-image CADe time was significantly shorter (0.03 s vs. 2.86 s, p < 0.001). CADe showed higher sensitivity in certain subgroups, although these findings should be interpreted cautiously given the small sample size. Conclusions:No significant difference in sensitivity was observed between CADe and endoscopist detection for MGCs after ESD, and the absolute sensitivity remained low. Further improvements are needed before clinical implementation of CADe as a double-checking tool. Trial Registration:The authors have confirmed clinical trial registration is not needed for this submission.
Background and Objectives:Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an alternative therapeutic option for unsuccessful endoscopic retrograde cholangiopancreatography in patients with malignant biliary obstruction. Procedure-related adverse events (AEs), such as bile leakage and peritonitis, can lead to prolonged hospitalization and delay the initiation of chemotherapy for underlying malignancies. This study aimed to identify factors associated with the development of peritonitis following EUS-HGS. Methods:Consecutive patients who underwent initial EUS-HGS between July 2016 and November 2022 were retrospectively evaluated. We assessed the preprocedural characteristics (cholangitis and duodenal invasion) and intraprocedural technical factors (small bile duct diameter, short hepatic parenchymal distance at puncture, antegrade stenting, and the use of a plastic stent for HGS). Multivariate logistic regression analysis was conducted to evaluate the factors associated with peritonitis after EUS-HGS. Results:A total of 188 patients were included. The cause of biliary obstruction was malignancy in 96% of the cases, with the majority being pancreatic cancer. The rate of early AEs was 15% and included peritonitis (7%), pancreatitis (3%), cholangitis (3%), cholecystitis (1%), and bleeding (1%). Multivariable logistic regression analysis revealed that the diameter of a punctured bile duct ≤3 mm (odds ratio, 4.0; 95% confidence interval, 1.1-15; p = 0.039) independently increased the risk of peritonitis after EUS-HGS. Conclusions:A punctured bile duct diameter of ≤3 mm was identified as a significant independent risk factor for the development of peritonitis after EUS-HGS. Trial Registration: N/A.
A 72-year-old man developed a hepatic artery pseudoaneurysm (HAP) caused by a liver abscess due to acute cholangitis and choledocholithiasis. He was successfully treated by transcatheter arterial embolization (TAE) with tornado microcoils. Two years later, he developed severe acute cholangitis caused by a biliary stone formed around a coil that had migrated into the common bile duct, termed "Coildocholithiasis." The stone was removed successfully, while several coils remained in the liver. He subsequently experienced repeated "Coildocholithiasis" and cholangitis, and after the third episode of coil migration, no coil remained in the liver. Since HAP can be fatal if it ruptures, TAE has become a standard treatment for HAP and other arterial aneurysms. Coil migration to other organs is a rare late-onset complication. This is the first report of three consecutive coil migrations in one patient, discussing the mechanisms of migration and whether prophylactic endoscopic removal should be considered once asymptomatic coil migration into the bile duct is identified.
Objectives:To review the evidence base, evolution, outcomes, adverse events (AEs), and management for third-space endoscopy (TSE) procedures for management of benign motility disorders. Methods:This review examines TSE procedures for motility disorders, reviewing the current available techniques, success, outcomes, and long-term outcomes from the literature. Results:Peroral endoscopic myotomy (POEM) for achalasia cardia is now established as first-line therapy, endorsed by the American Society for Gastrointestinal Endoscopy, American College of Gastroenterology, Society of American Gastrointestinal and Endoscopic Surgeons, and international expert bodies, with long-term clinical success exceeding 90% at 7 years. Since 2010, the technique has evolved considerably, with refinements in myotomy length, orientation, and depth, along with intraoperative use of an endoluminal functional lumen imaging probe to optimize outcomes and reduce post-procedure gastroesophageal reflux (GER). The TSE platform has since expanded to spastic esophageal disorders, esophagogastric junction outflow obstruction, Zenker's and epiphrenic diverticula (Z-POEM/D-POEM), refractory gastroparesis (gastric per-oral endoscopic pyloromyotomy), and Hirschsprung's disease. Techniques have also been modified along the way to achieve better results while minimizing AEs. Post-POEM GER, occurring objectively in 40%-55% of patients, remains the principal long-term challenge, and multiple modalities have been explored to address it. Conclusions:TSE has fundamentally transformed the management of benign gastrointestinal motility disorders, with POEM serving as the paradigm for the shift from surgical to endoscopic treatment. Ongoing technical refinement, GER mitigation strategies, and emerging innovations are poised to further advance the field. Trial Registration:N/A.
Sedation is an essential component of upper gastrointestinal endoscopy because it reduces patient discomfort and anxiety while improving patient acceptance and procedural quality. In Japan, benzodiazepines such as midazolam and opioid analgesics have long been widely used in routine clinical practice; however, many of these agents historically lacked formal insurance approval for sedation during gastrointestinal endoscopy. Propofol is also a useful sedative because of its rapid onset and recovery, but its use in Japan has been limited because of concerns regarding respiratory and cardiovascular depression and the need for management by anesthesia-trained personnel. Against this background, the approval of remimazolam for sedation during gastrointestinal endoscopy in June 2025 represented a major turning point in Japanese endoscopic sedation practice. Remimazolam is an ultra-short-acting benzodiazepine rapidly metabolized by carboxylesterases and reversible with flumazenil. Japanese phase III trials demonstrated high sedation success rates and rapid recovery during upper gastrointestinal endoscopy, including in elderly patients. Compared with midazolam, remimazolam shortened awakening and ambulation times, whereas compared with propofol, it may cause fewer respiratory and cardiovascular adverse events. This review summarizes the current status of upper gastrointestinal endoscopic sedation in Japan, focusing on the clinical evidence and positioning of the newly approved ultra-short-acting benzodiazepine, remimazolam.
Endoscopic retrograde cholangiopancreatography (ERCP) in patients with situs inversus totalis (SIT) and Billroth II reconstruction is technically challenging because of mirror-image anatomy, altered access to the papilla, and inverted papillary orientation. A 56-year-old man with a history of distal gastrectomy with Billroth II reconstruction for a gastric ulcer 20 years earlier was found to have common bile duct stones on pre-ERCP imaging. ERCP was performed in the prone position, as in conventional ERCP, with the endoscopist standing on the patient's right side. A short-type single-balloon enteroscope was advanced through the afferent limb to the major papilla. Biliary cannulation was achieved using a standard ERCP catheter without positional modification or sphincterotome. Cholangiography confirmed small common bile duct stones. Endoscopic papillary balloon dilation with an 8-mm balloon was performed, followed by stone extraction using a basket catheter. Final cholangiography confirmed complete stone clearance, and no adverse events, including post-ERCP pancreatitis, occurred. This case suggests that favorable alignment between the 7 o'clock working-channel direction and the bile duct axis may allow conventional-position ERCP in selected patients with SIT and Billroth II reconstruction.
Early gastric cancer (EGC)-like advanced gastric cancer (AGC) is a rare entity that mimics superficial disease despite deep invasion. We report a case of EGC-like AGC with focal enteroblastic differentiation in which subserosal invasion was underestimated because of its superficially appearing endoscopic features. A subtle submucosal tumor (SMT)-like change was recognized only retrospectively after clinicopathological correlation. Endoscopy revealed a depressed 0-IIc-appearing lesion with fold convergence toward a single point, leading to a diagnosis of UL1; however, no mound-like elevation was observed. Retrospective review identified a subtle SMT-like protrusion on the anterior wall, slightly apart from the main depression. Endoscopic submucosal dissection (ESD) was performed for presumed EGC. During ESD, a whitish cord-like structure extending from the muscularis propria was identified at the corresponding site. The ESD specimen showed submucosal invasion with a positive vertical margin, and additional surgical resection revealed subserosal invasion. Histopathological examination of the surgical specimen demonstrated tubular adenocarcinoma (tub2>por1/tub1) with focal enteroblastic differentiation and subserosal invasion (pT3 [SS]) without lymph node metastasis but with venous invasion (V1c). Immunohistochemistry showed CK7 positivity, CK20 negativity, and partial expression of CDX2, glypican-3, and SALL4, whereas AFP was negative. Clinicopathological correlation showed that the retrospectively recognized SMT-like change corresponded to the deepest invasive component. This case highlights the difficulty of preoperative depth assessment in EGC-like AGC. Careful integration of endoscopic, intraoperative, and clinicopathological findings may help avoid underestimation of tumor depth.
Endo-hepatology is a rapidly evolving field encompassing endoscopic diagnosis and treatment of hepatobiliary diseases, primarily using endoscopic ultrasound (EUS). Since its conceptualization in 2012, the field has expanded dramatically alongside advances in interventional EUS. A landmark 2024 review broadened the concept to include endoscopic management of hepatobiliary diseases using interventional EUS/endoscopic retrograde cholangiopancreatography and advanced imaging technologies. In portal hypertension (PH), diagnostic applications include EUS-based variceal hemodynamic assessment, EUS-guided shear wave elastography, EUS-guided porto-systemic pressure gradient measurement (EUS-PPGM), EUS-guided liver biopsy (EUS-LB), and portal vein sampling. Therapeutic applications include EUS-guided vascular embolization for gastric, esophageal, and ectopic varices; portosystemic shunt obliteration for refractory hepatic encephalopathy; radiofrequency ablation of hepatocellular carcinoma; and emerging procedures such as intrahepatic portosystemic shunt creation and portal vein stenting. EUS-PPGM enables direct, minimally invasive portal pressure measurement and correlates strongly with the hepatic venous pressure gradient (HVPG). It may offer particular advantages in pre-sinusoidal PH, such as porto-sinusoidal vascular disorder, and in conditions with mixed sinusoidal and presinusoidal components, including metabolic dysfunction-associated steatotic liver disease, where HVPG may underestimate portal pressure. The "one-stop" concept integrates portal pressure measurement, LB, liver stiffness assessment, and variceal evaluation and treatment within a single endoscopic session. EUS-guided coil plus cyanoacrylate injection has demonstrated favorable efficacy and safety for gastric varices, while EUS-LB provides diagnostic accuracy comparable to percutaneous biopsy with less post-procedure pain. By integrating diagnostic and therapeutic procedures, endo-hepatology bridges endoscopy and hepatology and may provide comprehensive, minimally invasive, and personalized management of PH and chronic liver disease.
Ulcerative colitis-associated neoplasia (UCAN) is often difficult to delineate because chronic inflammatory changes obscure lesion borders. Accurate assessment of lesion extent is essential for curative endoscopic submucosal dissection (ESD), yet conventional white-light imaging frequently fails to clearly define lateral tumor spread. We report four patients with UCAN in whom crystal violet staining for colitis-associated neoplasia (CV-SCAN) was used to delineate lesion extent before ESD. All patients had ulcerative colitis in clinical remission and underwent surveillance colonoscopy. In these four patients, UCAN was identified as CV-neoplasia (CV-N) areas during CV-SCAN, whereas lesion borders remained indistinct on conventional white-light imaging. After histological confirmation by targeted biopsy, a repeat CV-SCAN was performed to determine lesion extent before ESD. In three patients, the CV-N-positive areas corresponded well with the pathological extent of neoplasia, and en bloc curative resection was achieved. One patient had a positive horizontal margin after the initial ESD. During an additional procedure, residual UCAN was again visualized as a CV-N-positive area and was successfully removed by additional ESD. No procedure-related adverse events or local recurrences were observed during follow-up. These cases suggest that CV-SCAN may facilitate delineation of UCAN before ESD and may help identify residual neoplasia that is difficult to recognize using white-light imaging alone. CV-SCAN should be considered an adjunctive technique that complements conventional endoscopic modalities rather than a standalone approach for lesion delineation.
