Digestive Endoscopy最新文献

Self-expanding metallic stents (SEMS) are a well-established treatment for acute malignant colonic obstructions, serving as palliative care for unresectable tumors or as a bridge to elective surgery, thereby avoiding emergency enterostomy [1]. While their efficacy in left-colon malignancies is well documented, their use in proximal colonic applications, particularly for ileocecal stenosis, remains underreported. The technical challenges of placing stents in the ileocecal region arise from anatomical complexities: the greater distance from the anus, the acute angulation at the ileocecal valve (ICV), and tumor-induced luminal distortion, all contributing to higher single-attempt failure rates [2, 3]. This report introduces a novel cholangioscopy-assisted technique that successfully achieved precise stent placement across the ICV in a patient with a malignant ileocecal tumor-induced intestinal obstruction (Video S1). A 61-year-old male presented with acute abdominal pain. CT imaging revealed an ileocecal tumor with suspected ileal intussusception, proximal small bowel dilation (Figure 1), and liver/lung metastases. Following multidisciplinary consultation, palliative SEMS placement was selected. Initial colonoscopy (CF-HQ290i, Olympus, Japan) demonstrated a circumferential, cauliflower-like tumor with complete ICV destruction and severe luminal stenosis. Conventional guidewire navigation using a bowie knife failed to traverse the tumor. The subsequent use of an ultra-slim cholangioscope (VedVision, Vedkang Medical, China; outer diameter 3.1 mm) allowed direct visualization and stricture traversal. After advancing the guidewire through the cholangioscope's working channel, a 10-cm uncovered SEMS was successfully deployed under dual endoscopic and fluoroscopic guidance. For cases where conventional stent placement is hindered by the ileocecal region's anatomical complexity or severe stenosis, the ultra-slim cholangioscope reliably traverses strictures under direct visualization. This method provides real-time intraluminal guidance for precise guidewire advancement and stent deployment, significantly enhancing procedural success rates and avoiding complications associated with blind manipulation. It broadens access to stent-based interventions, offering a viable bridging strategy for patients unsuitable for immediate or emergency surgery.

Shanbin Wu: original draft and video editing. Yan Zhang: review and editing. Guoliang Zhao: surgical operator and supervisory guidance.

The authors declare no conflicts of interest.

Esophagogastric varices (EGVs) are a disease that occurs as a complication of the progression of liver cirrhosis, and since bleeding can be fatal, regular endoscopy is necessary. With the development of artificial intelligence (AI) in recent years, it is beginning to be applied to predicting the presence of EGVs, predicting bleeding, and making a diagnosis and prognosis. Based on previous reports, application methods of AI can be classified into the following four categories: (1) noninvasive prediction using clinical data obtained from clinical records such as laboratory data, past history, and present illness, (2) invasive detection and prediction using endoscopy and computed tomography (CT), (3) invasive prediction using multimodal AI (clinical data and endoscopy), (4) invasive virtual measurement on the image of endoscopy and CT. These methods currently allow for the use of AI in the following ways: (1) prediction of EGVs existence, variceal grade, bleeding risk, and survival rate, (2) detection and diagnosis of esophageal varices (EVs), (3) prediction of bleeding within 1 year, (4) prediction of variceal diameter and portal pressure gradient. This review explores current studies on AI applications in assessing EGVs, highlighting their benefits, limitations, and future directions.

Recently, various endoscopic techniques performed under saline immersion have been reported. However, in such settings, mixing of blood and water results in poor endoscopic visibility, making it difficult to identify the appropriate hemostatic point [1]. To address this, we developed a gas-free immersion (GFI) system that employs a hood with a 4-mm tapered tip and saline to generate turbulence within the hood [2, 3]. This turbulence is produced by pressing the air/water valve button, allowing the endoscopic view to be maintained without using CO₂. Recently, the flushing forced method was reported as a useful precoagulation technique because in saline floating environments, arc formation and spark are suppressed because the electrical current scattered into the surrounding field [4]. We report flow-assisted coagulation using GFI (GFI-FAC), which facilitates hemostasis under saline by applying flow within the narrow hood using the water valve button.

The patient had a 35-mm type 0-I tumor with fibrosis in the cecum (Figure 1, Video S1). We performed an en bloc ESD using GFI-FAC. First, a mucosal incision was made on the anal side. The submucosa was dissected, and the blood vessels were precoagulated by allowing saline to flow around the knife blade while pressing the water valve button in coagulation mode (VIO300D: Forced E4-50W, VIO3: Forced E3.5–4.0), without causing sparking. If active hemorrhage occurred, hemostasis was achieved by coagulating while confirming the hemostatic point with saline irrigated in the hood. Dissection of the submucosa and fibrosis was performed using the cutting mode, and the tumor was safely removed. The pathological diagnosis was intramucosal carcinoma, and the tumor was completely resected. Defect closure was achieved using the reopenable-clip over the line method, and the patient was discharged without adverse events [5]. GFI-FAC can be used for achieving safe hemostasis under saline-immersion conditions by creating turbulence in the hood.

Tatsuma Nomura made substantial contributions to the conceptualization of the study. Katsumi Mukai contributed substantially to the revision of the manuscript.

The authors declare no conflicts of interest.