Digestive Endoscopy最新文献

In malignant hilar biliary obstruction, transpapillary drainage alone is often difficult [1, 2]. Percutaneous transhepatic drainage or additional endoscopic interventions may be required, but external fistula formation can reduce quality of life [3-5]. We report a case in which extensive right hepatic drainage was achieved using the biliary skewering technique combined with endoscopic ultrasound-guided hepaticoduodenostomy (EUS-HDS) (Video S1). A 72-year-old woman with hilar cholangiocarcinoma had separated intrahepatic bile ducts, with the right ducts divided to tertiary branches (Figure 1A,B). Transpapillary stents had been placed into the Segment 2 and Segment 5 branches at a previous hospital; however, drainage remained insufficient, and additional right hepatic drainage was performed under EUS guidance. Using a linear echoendoscope (EG-740UT; FUJIFILM), the Segment 6 and Segment 7 branches were skewered across the liver parenchyma in a single puncture with a 19-gauge needle (EZ Shot 3 Plus; Olympus) (Figure 2A,B). An uncovered self-expandable metal stent (UCSEMS; ZEOSTENT V, 8 mm × 6 cm; ZEON MEDICAL) was deployed from the Segment 7 branch to the Segment 6 branch (Figure 2C). A partially covered SEMS (ZEOSTENT HG, 8 mm × 10 cm; ZEON MEDICAL) was then inserted from the Segment 6 branch to the duodenum, with its uncovered portion overlapping the UCSEMS (Figure 2D). Similarly, the separated Segment 5 branches were bridged using a UCSEMS (ZEOSTENT V, 8 mm × 6 cm; ZEON MEDICAL) (Figure 2E–G). A fully covered SEMS (HANAROSTENT Biliary Benefit, 6 mm × 10 cm; Boston Scientific) with manually created distal side holes was placed from the Segment 5 branch to the duodenum as the HDS stent (Figure 2H). This combined approach enabled multi-segmental right hepatic drainage without external fistula formation, resulting in resolution of jaundice and allowing continued chemotherapy in this complex hilar obstruction (Figure 1C–E).

Hiroki Koda: study conception, procedure performance, video editing, data acquisition, and manuscript drafting. Kazuo Hara: supervision, interpretation of findings, and critical manuscript revision. Tomoki Ogata: assistance with endoscopic procedure and data management.

The authors have nothing to report.

The authors declare no conflicts of interest.

WEO Newsletter Editor: Nalini M Guda MD, MASGE, AGAF, FACG, FJGES

A 41-year-old woman with Mayer–Rokitansky–Küster–Hauser syndrome (type I), a congenital absence of the uterus and upper vagina, underwent sigmoid colon vaginoplasty at age 18 and was followed at our gynecology department. She presented with a 10-month history of intermittent neovaginal bleeding and dyspareunia. A manual neovaginal examination was unremarkable, but persistent symptoms prompted referral to our department (Gastroenterology) for further evaluation. Vaginoscopy (EVIS X1 and GIF-XZ1200, Olympus Corp., Tokyo, Japan) revealed continuous erythema, edema, erosions, and loss of vascular pattern, resembling ulcerative colitis, in the neovaginal sigmoid colon (Figure 1a,b). Biopsy histology showed chronic active colitis with crypt distortion, cryptitis, and goblet cell depletion (Figure 1c,d). Bacterial culture and Treponema pallidum PCR were negative. Colonoscopy showed only minor aphthous erosions confined to the anal verge, with no lesions in the upstream rectum or colon. She had no gastrointestinal symptoms suggestive of ulcerative colitis, such as diarrhea, hematochezia, or abdominal pain. From these findings, she was diagnosed with isolated neovaginal diversion colitis. She was initially treated with intravaginal budesonide foam enemas (2 mg, once daily) for 7 weeks and advised to refrain from vaginal intercourse; however, symptoms persisted. Subsequently, mesalazine vaginal suppositories (1000 mg, once daily) were initiated with the aid of a vaginal prosthesis to facilitate drug delivery to the neovaginal blind end, resulting in marked symptom improvement within 1 week. Follow-up vaginoscopy after 7 weeks demonstrated mucosal normalization, and histology confirmed resolution of inflammation (Figure 2). She resumed vaginal intercourse while continuing mesalazine suppositories, with only occasional trace bleeding and no other symptoms for 13 months. Neovaginal diversion colitis, also called “diversion neovaginitis,” may result from nutritional deprivation (e.g., short-chain fatty acids) [1]. Despite treatments like short-chain fatty acid enemas, mesalazine, or corticosteroids, no standardized treatment has been established [1, 2]. Accurate endoscopic and histological assessment enables effective medical management and preserves sexual function.

Shinichiro Kawatoko designed the study, managed the patient's care, performed endoscopic evaluations, reviewed histological specimens, and drafted the manuscript. Marimo Mori and Junji Umeno critically reviewed and revised the manuscript for important intellectual content. All authors have read and approved the final version of the manuscript.

The authors have nothing to report.

The authors declare no conflicts of interest.

Gastric subepithelial lesions (SELs) < 20 mm are frequently identified during routine endoscopy and account for approximately 90% of all SELs. Although most are benign, a substantial proportion represents gastrointestinal stromal tumors (GISTs), which carry malignant potential even at this small size. Histological confirmation is critical for appropriate risk assessment and treatment planning. However, the diagnostic yield of endoscopic ultrasound-guided tissue acquisition (EUS-TA) is limited for SELs < 20 mm due to technical challenges such as lesion mobility and short needle stroke. Mucosal incision–assisted biopsy (MIAB), which enables direct visualization and targeted sampling, has emerged as a practical alternative. This narrative review summarizes current evidence on endoscopic diagnostic approaches for SELs < 20 mm, including both sampling methods (EUS-TA, MIAB) and nonsampling techniques such as contrast-enhanced EUS, elastography, and artificial intelligence (AI)-assisted image analysis. Each modality has distinct advantages and limitations, and selection should be based on lesion characteristics, endoscopist experience, and resource availability. Nonsampling modalities offer complementary information and are expected to become increasingly relevant. A comprehensive understanding of available diagnostic techniques is essential to support accurate clinical decision-making for SELs < 20 mm.

Colorectal underwater endoscopic mucosal resection (UEMR) is widely performed because of its higher en bloc and R0 resection rates, as well as lower local recurrence rates compared with conventional EMR [1, 2]. However, identifying the oral side of a lesion can occasionally be challenging in underwater conditions, leading to piecemeal resection. Here, we demonstrate a technique for partial submucosal injection on the oral side during UEMR (PI-UEMR) for a flat colorectal lesion. A 60-year-old man underwent colonoscopy, which revealed a 13-mm flat reddish lesion in the transverse colon (Figure 1a). Endoscopy with narrow-band imaging showed an irregular surface and vessel pattern, suggesting an advanced adenoma (Figure 1b). Underwater conditions made it difficult to continuously visualise the oral side of the lesion without the assistance of a sheath, raising concerns regarding the possibility of piecemeal resection (Figure 1c). Therefore, we decided to perform PI-UEMR. After a partial submucosal injection of 3 mL of saline solution on the oral side of the lesion, the overall visualisation improved (Figure 1d). We captured the lesion while maintaining the snare tip on the oral side. En bloc resection was achieved without any complications (Figure 1e, Video S1). Pathological examination revealed a high-grade adenoma with tumour-free margins (Figure 2). PI-UEMR, which involves local injection only on the oral side of the lesion, can improve the visibility of the oral margin while maintaining the floating effect [3], an original advantage of the underwater resection technique. A previous report demonstrated that PI-UEMR achieved better treatment outcomes than conventional UEMR in the duodenum [4]. The detailed presentation of this case not only suggests the potential applicability of PI-UEMR to colorectal flat lesions for which piecemeal resection is a concern with conventional UEMR [5], but also may contribute to the adoption of this technique as a simple and reproducible procedure.

H.K.: conception and design of the study. H.K., K.S. and T.I.: drafting and revision of the manuscript and final approval of the manuscript.

The authors have nothing to report.

The authors have nothing to report.

The authors declare no conflicts of interest.