Digestive Endoscopy最新文献

Pancreatic pleural fistula (PPF) is a rare but potentially life-threatening complication. It is most associated with chronic pancreatitis [1], whereas pancreatic cancer–related PPF is uncommon. Although endoscopic treatment has been reported to be effective for PPF [2], pancreatic duct drainage in cases with pancreatic divisum remains technically challenging [3]. Although the usefulness of stent placement using a novel designed device delivery system (EndoSheather; Piolax Medical Device, Kanagawa, Japan) [4] and internalization of endoscopic nasal biliary drainage tube using a loop cutter [5] have been reported, there are no reports describing their use for pancreatic duct drainage.

A 67-year-old woman receiving chemotherapy for pancreatic cancer developed rupture of a pancreatic pseudocyst one month after chemotherapy initiation. Two months later, massive left-sided pleural effusion developed, and the patient was admitted to the hospital with dyspnea. A chest tube was inserted, and fluid analysis showed elevated amylase levels (> 60,000 IU/L). Previous computed tomography demonstrated a pancreatic duct stricture in the pancreatic body and pancreatic divisum (Figure 1).

Endoscopic retrograde cholangiopancreatography was performed, and cannulation of the minor papilla was achieved. However, advancement of the catheter and 5-Fr endoscopic nasal pancreatic drainage (ENPD) tube beyond the stricture was difficult. Then, a device delivery system enabled passage through stricture. The ENPD tube was advanced through the device, enabling placement of the ENPD tube beyond the stricture. The chest tube was removed 5 days after ERCP, and the ENPD tube was internalized 1 week later using a loop cutter. No procedure-related adverse events occurred, and PPF did not recur (Figure 2, Video S1).

When an ENPD tube placement is difficult due to severe pancreatic duct stricture, especially with pancreatic divisum, the use of a device delivery system allows reliable placement of an ENPD tube across the stricture and internalization of an ENPD tube with a loop cutter may be useful.

Conception: T.M. and T.T.; acquisition: T.M.; drafting the work: T.M.; revising: T.T. and N.S.; final approval: N.S.; all authors have read and agreed to the published this version of the manuscript.

The authors have nothing to report.

The authors declare no conflicts of interest.

We appreciate Park's thoughtful commentary on our nationwide cohort showing that extensive (open-type) endoscopic gastric atrophy (GA) is associated with higher esophageal squamous cell carcinoma (ESCC) incidence among regular screening esophagogastroduodenoscopy (EGD) examinees in Japan [1, 2].

Residual and unmeasured confounding warrant consideration. In our health check-up setting, smoking and alcohol were recorded as ever/never per the Ministry of Health, Labour and Welfare's standard questionnaire, which lacks cumulative exposure items, an acknowledged limitation [2, 3]. Even so, alcohol remained significantly associated with ESCC, and open-type GA consistently emerged as an independent risk factor (adjusted HR 2.7, 95% CI 1.6–4.7). We agree that diet, oral hygiene and socioeconomic context are relevant; future prospective designs should capture quantitative exposures and these variables systematically.

To address baseline imbalances (age, sex), we combined multiple imputation with multivariable Cox regression and prespecified subgroup analyses, adjusting for age, sex, alcohol, smoking, etc. Findings were concordant across imputed and complete case analyses and subgroups. Propensity-based methods were considered a priori but deprioritized due to few ESCC events (n = 77) and a three-category exposure, which risked unstable weights or loss of effective sample size.

Regarding detection bias, baseline GA was adjudicated independent of outcomes, incidence was expressed per person-years, and time-to-event modeling accounted for follow-up. Even in a sensitivity model additionally adjusting for the number of EGDs during follow-up, the association for open-type GA was materially unchanged (adjusted HR 2.80, 95% CI 1.64–4.80), supporting robustness.

Mechanistically plausible pathways (hypochlorhydria and oral–esophageal microbial influences) merit integrative prospective studies (microbiome, metabolomics, reflux characterization). In summary, within a large screening cohort, open-type GA remained an independent risk marker for ESCC. While residual confounding cannot be fully excluded, complete negation of the association appears unlikely; our study is hypothesis-generating and could motivate mechanistic research.

K.W. drafted the manuscript; S.F. and K.I. critically revised it. All authors approved the final version.

The authors have nothing to report.

The authors declare no conflicts of interest.

A 45-year-old woman was referred to our hospital with abdominal pain. Magnetic resonance cholangiopancreatography demonstrated a common bile duct (CBD) stone (Figure 1). Endoscopic retrograde cholangiopancreatography confirmed an impacted stone at the confluence of the cystic duct and the CBD. Because of distal bile duct narrowing, electrohydraulic lithotripsy was performed under peroral cholangioscopy (POCS), followed by stone extraction using a basket catheter. After stone removal, POCS revealed a protruding lesion at the cystic duct orifice (Figure 2). The lesion was isochromatic with the surrounding mucosa and was suspected to be an inflammatory polyp. Because its size and location made conventional cholangioscopic forceps inadequate for obtaining sufficient tissue, and direct cholangioscopic manipulation was limited by the narrow distal bile duct, the lesion was resected as a complete excisional biopsy to achieve both a definitive histopathological diagnosis and complete removal. Under fluoroscopic guidance, the lesion was gently captured with a rotatable basket catheter (RASEN2; KANEKA Medical, Japan). By carefully rotating the catheter, the lesion was detached, and complete excision was achieved without bleeding or perforation. Subsequent POCS confirmed complete resection endoscopically, with no residual lesion or procedure-related adverse events, thereby demonstrating the safety of this approach. Histopathological examination revealed an inflammatory fibrous polyp composed of fibrous stroma with mild epithelial proliferation and inflammatory cell infiltration. No recurrence was observed during follow-up [1-3]. This video demonstrates that a rotatable basket catheter, originally designed for bile duct stone extraction, can be considered a diagnostic and therapeutic option in carefully selected cases of intraductal biliary lesions when conventional cholangioscopic devices are not applicable.

T.U. contributed to the conception and design of the study, performed the endoscopic procedure, and drafted the manuscript. S.U. and S.K. contributed to data acquisition and interpretation. All authors critically revised the manuscript and approved the final version.

The authors have nothing to report.

The authors declare no conflicts of interest.

Endoscopic submucosal dissection (ESD) is technically demanding with the main limitation on the lack of effective countertraction. Existing countertraction methods such as clip-related techniques only provide unidirectional static traction force that may restrict their utility in complicated colorectal ESD. The magnetic countertraction system provides dynamic force by manipulating an external magnetic source. We designed a novel magnetic countertraction system with an internal magnet retractor introducible via the endoscopy channel and the external magnetic effector mounted on a robotic arm that could be easily manipulated. We evaluated the performance and safety of the system in an ex vivo randomized crossover study. ESD was performed on ex vivo porcine colon models with standardized 3 cm target lesions marked at gravity-dependent locations. Endoscopists performed the ESD in pairs, randomized to magnetic countertraction (MAG-ESD) or conventional ESD (C-ESD) first to minimize bias from the learning effect. During MAG-ESD, a flexible internal magnetic retractor was deployed via the endoscopic channel and anchored to the lesion margin. A robotic arm-mounted external permanent magnet (EPM) was positioned above the colon model to engage the retractor and provide dynamic countertraction. Seventy-two ESD (36 MAG-ESD and 36 C-ESD) were performed by 18 endoscopists. MAG-ESD significantly reduced procedure time by 20.4% (p = 0.0002) and workload (NASA-TLX mean difference: −19.81, 95% CI: −25.42 to −14.19). All procedures achieved en bloc resection. MAG-ESD had significantly fewer complications (OR = 0.782, 95% CI: 0.644–0.949), including lower rates of perforation and muscle injury. The novel magnetic countertraction system significantly improved procedural efficiency, reduced operator workload, and enhanced safety in ex vivo colonic ESD.

A 21-year-old man complained about progressive dysphagia and hoarseness for 9 months. Endoscopy revealed a giant, lobular 0-Ip mass (stalk diameter 1.5 cm) protruding into the esophageal lumen 20–28 cm from the incisors, with hair on the surface (Figure 1A). Further endoscopic ultrasonography showed that the mass was 3.92 cm × 2.66 cm, originating from submucosa, with mixed echo, clear demarcation, and intact muscularis propria (Figure 1B). Enhanced chest CT also showed a 4.3 cm × 3.2 cm × 10.7 cm mass at the esophageal wall (Figure 1C). Endoscopic submucosal dissection (ESD) of the mass was performed after the patient's consent. Under general anesthesia and intubation, standard ESD procedures were performed (Video S1) with dual knife and insulated tip knife. En bloc resection of the mass was successful, without perforation or bleeding (Figure 1D–F). The attempt to retrieve the whole mass failed. Therefore, we fragmented the mass and retrieved them using a snare (Figure 1G,H). The wound was finally closed with titanium clips (Figure 1I). The entire procedural time was 104 min. The resected mass (Figure 2A) was pathologically diagnosed as mature teratoma (Figure 2B). No residue or recurrence of the tumor was found upon visit (Figure 2C). Mediastinal teratoma are frequently reported [1], but esophageal teratoma is rare [2]. Usually, patients may be referred to surgical or thoracoscopic resection for curative treatment. Considering the benign nature and clear demarcation of the mature teratoma, ESD is advantageous for its en bloc endoscopic resection. To the best of our knowledge, endoscopic management of giant esophageal teratoma has not been reported. Although the size of the tumor was over 40 mm and the whole procedural time was 104 min, posing risk of technical difficulty of ESD [3], the actual tumor dissection time was 9 min and the stalk size was 15 mm in our case, presenting no obvious resection limitation. Our case shows ESD is feasible for esophagus-derived teratoma, and therefore, may provide a safer, cheaper, and less invasive replacement of surgical interventions [4].

Yuhang Zhang drafted the manuscript and the video clip. Ruizhi Wang collected the material and made critical revisions. Bing Hu performed the endoscopic resection and conceptualization.

This work was supported by National Natural Science Foundation of China (82170675) and 1·3·5 project for disciplines of excellence, West China Hospital, Sichuan University (ZYJC21011).

Informed consent was obtained from the patient to publish these images.

The authors declare no conflicts of interest.