Surveillance endoscopy in a 47-year-old woman with previous hypopharyngeal chemoradiotherapy and esophageal endoscopic submucosal dissection (ESD) revealed a 12-mm superficial squamous cell carcinoma at the cervical esophagus near the inlet. ESD achieved en bloc resection with a half-circumferential mucosal defect, and histopathology showed pT1a lamina propria mucosae with negative margins. For stricture prophylaxis, triamcinolone was injected into the post-ESD defect, oral prednisolone was tapered over several months, and prophylactic endoscopic balloon dilation was performed three times at 3-4-week intervals. Three months after ESD, a 10-mm white-coated lesion appeared at the inlet and progressively enlarged. Under intravenous sedation, detailed endoscopic assessments and biopsies were limited by the complex location, and the biopsy suggested neoplastic cells with marked degeneration. Due to progressive odynophagia and poor oral intake, endoscopic re-evaluation under general anesthesia was performed. Using Sato's curved laryngoscope, the lesion was clearly visualized as a semipedunculated mass arising from the post-ESD site and was completely resected for diagnosis and symptom relief. Histopathology revealed inflammatory granulation tissue without malignancy. Symptoms resolved promptly with no recurrence during 6 months of follow-up. This case highlights the development of exuberant granulation tissue at the post-ESD site in the cervical esophagus during intensive stricture prophylaxis. Although this rare finding likely reflects multiple overlapping factors, endoscopic evaluation and treatment were successfully performed while avoiding overtreatment.

Background and Study Aims: Endoscopic duodenal findings remain undescribed after long-term use of antacids despite their known effects on duodenal physiology. We identified scattered white spots (SWS) as an endoscopic finding of chronic acid suppression in the duodenum and aimed to confirm this association. Patients and Methods: In this single-centre, two-arm, retrospective study, we reviewed 200 patients who underwent outpatient oesophagogastroduodenoscopy (OGD): 100 consecutive patients receiving continuous acid-suppression (proton pump-inhibitors [PPI] or potassium-competitive acid blockers [P-CAB] ≥ 8 weeks) and 100 consecutive patients with no history of acid-suppression therapy. Two blinded expert endoscopists independently reviewed all white-light endoscopic images of the descending duodenum. SWS were graded 0 (absent/minimal), 1 (present) or 2 (dense). SWS-positive was defined as a combined score ≥ 2 of the two independent evaluators. Results: A total of 648 images from 200 patients (mean age 62 years, 62.5% male) were analysed. The acid suppression group included 58 PPI users and 42 P-CAB users. SWS-positive rates were significantly higher in the acid-suppression group than the non-suppression group (47% vs. 15%; OR 4.33; 95% CI, 2.20−8.50; P < 0.0001). Interobserver agreement was substantial (weighted κ = 0.77; 95% CI, 0.68−0.85). Multivariate logistic regression analysis revealed acid suppression therapy as an independent factor for SWS (adjusted OR 6.10; 95 % CI, 2.89−13.7; P < 0.0001). Conclusions: Long-term gastric acid suppression is significantly associated with the presence of duodenal SWS. Duodenal SWS associated with PPI and P-CAB are under-recognised, and further studies are warranted to determine their clinical significance.

Background: Endoscopic submucosal dissection (ESD) has become a first-line radical treatment for superficial colorectal neoplasias. ESD is technically demanding and associated with higher risks of adverse events (AEs) such as delayed bleeding and perforation. Prophylactic clip closure of mucosal defects after ESD is commonly practiced as a safety measure to prevent AEs. The closable size and shape of defects with conventional clips are restricted by the length and design of the clips. The MANTIS clip is a novel repositionable clip with tissue-piercing anchor prongs, enabling captured tissues to be arbitrarily manipulated. A few retrospective single-arm studies demonstrated that the novel clip reliably achieved closure of defects after colorectal ESD. Therefore, this study assessed the clinical advantage of using the MANTIS clip for closure of defects after colorectal ESD, comparing it with conventional clips. Methods: This study is a prospective, multi-centre, open-label, randomised controlled trial involving 10 Japanese high-volume tertiary medical centres. Participants undergoing colorectal ESD were randomly assigned (1:1) to either undergo MANTIS-assisted closure (MANTIS clips plus conventional clips) or closure using conventional clips alone. The primary endpoint was the complete closure rate. The secondary endpoints were closure time, closure speed, operator change, and post-ESD AEs. Findings: Of the 250 patients enrolled, 7 were excluded per group, leaving 236 patients analysed (MANTIS, n=120; conventional, n=116). The complete-closure rate was higher with MANTIS clips than with conventional clips (98·3% [118/120] vs. 88·8% [103/116]; absolute risk difference 9·5%, 95% Confidence Interval 3·4–15·7; p < 0.01). One severe AE, delayed bleeding, was observed in a case with partial closure in the conventional clip group. Among complete-closure cases, median closure time and speed did not significantly differ between the groups. Interpretation: MANTIS-assisted closure after colorectal ESD markedly increased the complete closure rates without exceeding procedure time, eliminating severe post-operative AEs.

BACKGROUND AND AIM:Resection of non-ampullary duodenal neuroendocrine tumors presents technical challenges. This study investigated the efficacy and safety of endoscopic mucosal resection using an over-the-scope clip compared to endoscopic mucosal resection with a ligation device and endoscopic submucosal dissection. METHODS:This retrospective multicenter study included 65 lesions (63 patients), categorized by resection method: endoscopic mucosal resection using an over-the-scope clip (n = 26), endoscopic mucosal resection using a ligation device (n = 17), and endoscopic submucosal dissection (n = 22). Patient characteristics, tumor details, and outcomes were systematically evaluated, with significance at p < 0.05. RESULTS:Endoscopic mucosal resection using an over-the-scope clip had a significantly shorter procedure time than endoscopic submucosal dissection (16 min [7-30] vs. 60 min [28-119], p < 0.001) and recorded no perforations. Endoscopic mucosal resection using a ligation device was employed for smaller lesions, while endoscopic submucosal dissection had challenges in achieving clear margins. Hospitalization duration was the longest for the endoscopic submucosal dissection group (endoscopic mucosal resection using an over-the-scope clip: 4 [3-7] days, endoscopic mucosal resection using a ligation device: 5 [4-8] days, endoscopic submucosal dissection: 7 [4-15] days, p < 0.001). Endoscopic mucosal resection using an over-the-scope clip exhibited a unique advantage for full-thickness resection. CONCLUSIONS:Endoscopic mucosal resection using an over-the-scope clip allows for full-thickness resection with fewer complications. While effective, endoscopic mucosal resection using a ligation device is less reliable for achieving clear vertical margins, and endoscopic submucosal dissection, suitable for larger tumors, has a longer duration and higher complication rate.

ABSTRACT A 75‐year‐old man presented with an esophageal subepithelial lesion (SEL) measuring 2.5 cm, first identified over a decade ago. The patient was followed up regularly with computed tomography and endoscopy and remained asymptomatic since then. However, over the past year, the patient developed dysphagia, and endoscopic evaluation revealed that the tumor had enlarged to 6.0 cm. Although nine endoscopic examinations with biopsies were performed, no definitive histopathological diagnosis was established. Endoscopic ultrasonography revealed that the tumor originated primarily from the submucosa. Given the rapid growth of tumor size and progressive symptoms, the tumor was removed with endoscopic submucosal dissection (ESD) in an en bloc manner. Histopathological analysis revealed a SEL characterized by vascular proliferation, thickening of the lamina muscularis mucosa, and inflammatory changes. No evidence of neoplasm was identified, suggesting the presence of a reactive lesion. The patient's dysphagia improved following ESD, and no recurrence was observed during a 15‐month follow‐up period. To date, no reports have documented rapidly growing esophageal SELs with abundant vascularization during follow‐up.

Closure of mucosal defects following colorectal endoscopic submucosal dissection (C‐ESD) is often performed to prevent post‐C‐ESD adverse events. However, large mucosal defect closure using conventional clips remains technically challenging. Here, we evaluated the feasibility of the novel endoclip with anchor prongs, called the MANTIS Clip (Boston Scientific, Tokyo, Japan), for mucosal defect closure after C‐ESD. This high‐volume retrospective study was conducted at a single center. From March until December 2023, consecutive patients who underwent post‐C‐ESD mucosal defect closure using MANTIS Clip to achieve complete closure were enrolled. Patient clinical characteristics and outcomes were evaluated. Closure of the mucosal defect using the MANTIS Clip was attempted following C‐ESD in 32 lesions. The median sizes of the resection specimens and the tumors were 32 mm (range, 17–100 mm) and 23.5 mm (range, 5–96 mm), respectively. The lesions were distributed between the cecum, ascending, transverse, descending, sigmoid, and rectum. Complete closure was achieved in 96.9% of cases (31/32). All lesions up to 61 mm in defect size were completely closed. The median closure time was 7.9 (range, 3.3–18.0) min. The median numbers of MANTIS Clip and additional conventional clips were 3 (range, 1–4) and 5 (range, 1–11), respectively. No adverse events associated with closure, post‐ESD bleeding, and delayed perforation occurred. MANTIS Clip closure for large post‐C‐ESD mucosal defects was found to be feasible and reliable with a high complete closure rate and a short procedure time.

Flexible endoscopy, initially developed for diagnosis and tissue sampling, has been adapted for therapeutic interventions, leading to the emergence of natural orifice transluminal endoscopic surgery (NOTES) in the 2000s. The need for a triangulation function to enhance the intuitiveness and safety of NOTES has prompted the development of dual-arm, flexible endoscopic robotic platforms. Although the global interest in NOTES has decreased in the last decade, no-scar surgery concepts are still being applied to other complex endoluminal interventions, such as endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR), with ongoing research and development. The application of robotics in flexible endoscopy may facilitate the standardization of these procedures and expedite their global spread. Various robotic platforms have been developed and tested in the preclinical and clinical settings to demonstrate their efficacy and safety. In this article, we review the publications on technology and elucidate their advantages and existing challenges.

This study aimed to evaluate the diagnostic utility of the ultra-thin endoscope (UTE) for superficial squamous cell carcinoma (SSCC) compared to magnifying endoscopy (ME) under narrow-band imaging. Participants underwent endoscopic examination, and images of pharyngeal and esophageal SCCs, as along with suspicious SSCC lesions, were collected using UTE and ME on the same day. Three image catalogs (UTE, ME-1, and ME-2) were created and reviewed by three expert endoscopists. ME-1 and ME-2 contained the same endoscopic images. The primary endpoint was the intra-observer agreement for diagnosing SCC. Eighty-six lesions (SCC = thirty-nine, non-SCC = forty-seven) in 43 participants were identified. The kappa values for the intra-observer agreement between UTE and ME-1 vs. the control (ME-1 vs. ME-2) were 0.74 vs. 0.84, 0.63 vs. 0.76, and 0.79 vs. 0.88, respectively. The accuracies for diagnosing SCC by UTE and ME-1 were 87.2% vs. 86.0%, 78.0% vs. 73,2%, and 75.6 vs. 82.6%, respectively, with no significant differences (p > 0.05). The rates of lesions that were diagnosed with confidence by UTE and ME-1 were 30.2% vs. 27.9%, 55.8% vs. 62.8%, and 58.1% vs. 55.8%, respectively. UTE demonstrates substantial diagnostic performance for SSCC in the pharynx and esophagus.

BACKGROUND AND AIM:Prophylactic closure with the over-the-scope clip (OTSC) after endoscopic submucosal dissection (ESD) of superficial non-ampullary duodenal epithelial tumors (SNADETs) has been reported to reduce postoperative adverse events (AEs). However, there are few evidences regarding AEs-associated factors and long-term outcomes of OTSCs. METHODS:From January 2011 to December 2020, 139 consecutive patients with SNADETs who underwent ESD followed by OTSC closure in five institutions were extracted in this retrospective study. The primary endpoint was the rate of postoperative AEs after prophylactic OTSC closure. The secondary endpoints were the complete closure rate, residual rate, and long-term AEs associated with residual OTSCs. RESULTS:The rate of complete closure of the mucosal defect was 97.3% (142) in 146 SNADETs, which were completely resected by ESD. Postoperative AEs, including delayed bleeding, delayed perforation, and localized peritonitis, occurred in 6.2%, 3.4%, and 2.1% of patients, respectively; however, all of the cases improved without surgical treatment. In the multivariate logistic regression analysis, the use of two or more OTSCs was a significant independent risk factor for postoperative AEs (odds ratio, 2.94; 95% confidence interval, 1.02-8.46; P = 0.046). The residual OTSC rate was 46.4% at 1 year postoperatively, and long-term AEs included duodenal erosions and ulcers associated with residual OTSCs. CONCLUSIONS:Prophylactic closure with OTSCs after duodenal ESD can provide acceptable short-and long-term outcomes for preventing postoperative AEs. However, multiple OTSCs were the independent risk factors of postoperative AEs due to the gaps between and near the OTSCs.

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.