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Endoscopic submucosal dissection (ESD) is an established treatment of superficial esophageal neoplasms. Common complications include bleeding, perforation, and stricture. However, delayed gastrointestinal perforation distant from the ESD site is exceptionally rare. We report the case of a woman in her 70s with a history of nonsteroidal anti-inflammatory drug (NSAID)-associated duodenal ulcer and Helicobacter pylori infection who underwent ESD for superficial esophageal squamous cell carcinoma. After eradication therapy and 2 months of proton pump inhibitor (PPI) use, both treatments were discontinued. Preoperative endoscopy confirmed a scarred duodenal ulcer. Intraoperative esophageal perforation occurred during ESD and was closed with clips. Postoperative computed tomography (CT) showed mediastinal emphysema without intra-abdominal free air. The patient was treated in high care with fasting and antibiotics, but without PPI therapy. Six days postoperatively, the patient developed acute abdominal pain. CT revealed free air near the duodenal bulb, and emergency endoscopy identified a 10-mm perforated duodenal ulcer at the scarred site. Endoscopic closure was unfeasible, and laparoscopic omental patch repair was performed. PPI therapy was resumed postoperatively, and the patient recovered uneventfully. This case suggests that stress-related mucosal disease may have contributed to duodenal perforation. Background risks included ulcer history and scarring, whereas alleviating factors included no NSAID/steroid exposure, eradicated H. pylori, and absence of infection at the esophageal perforation. Guidelines do not endorse routine PPI use after ESD, and consensus following iatrogenic perforation is lacking. This case suggests that prophylactic PPI therapy may be considered in patients with risk factors such as recent peptic ulcer disease or intraoperative perforation.

Endoscopic removal of accidentally ingested dental prostheses can be challenging as their irregular shapes can occasionally cause severe complications, such as gastrointestinal perforation. Here, we present the case of an older woman who was referred to our hospital following accidental ingestion of a bridge-type denture. Computed tomography revealed that the denture was lodged in the thoracic esophagus, with concurrent mediastinal emphysema. Endoscopic examination confirmed that the denture had penetrated the esophageal wall. Under general anesthesia, the denture was endoscopically removed using dual endoscopes, and a large esophageal perforation was closed with an over-the-scope clip (OTSC) and subsequently reinforced with Mantis clips. Although follow-up endoscopy 1 month later demonstrated remaining OTSC at the site of the esophageal perforation, 3-month follow-up endoscopy confirmed complete closure of the perforation. Overall, this case indicates the usefulness of the dual-endoscope approach for foreign-object removal and the OTSC system for closure of esophageal perforations, thus providing the chance of avoiding invasive treatment such as esophagectomy.

Subepithelial lesions (SELs) of the head and neck have a low diagnostic yield with mucosal biopsy and carry a bleeding risk. Among endoscopic ultrasound–tissue acquisition (EUS-TA) techniques, fine-needle biopsy (FNB) provides higher specimen adequacy and diagnostic accuracy than fine-needle aspiration (FNA). A forward-viewing curved linear-array echoendoscope (FV-EUS) is useful for mobile lesions and those in narrow spaces that are difficult to puncture with conventional oblique-viewing EUS (OV-EUS), but FV-EUS–guided EUS-FNB has not been reported for head and neck lesions.

We report a 72-year-old man in whom a lesion at the esophageal inlet was not apparent on initial upper gastrointestinal endoscopy performed with a small-caliber endoscope. Stenosis was subsequently noted at the time of endoscopic submucosal dissection for early gastric cancer. Contrast-enhanced computed tomography showed an approximately 20-mm solid mass on the posterior hypopharyngeal wall. Under general anesthesia with laryngoscopic exposure, an elevated subepithelial lesion without mucosal exposure was observed on the posterior pharyngeal wall. Using FV-EUS with a cap device attached to the scope tip, a 22 × 18 mm hypoechoic subepithelial mass was clearly visualized, and consecutive EUS-FNB was performed with a 22-gauge needle. No complications, including bleeding, occurred. Histopathology and immunohistochemistry demonstrated moderately differentiated squamous cell carcinoma, and the patient was referred for treatment as primary hypopharyngeal cancer. This case illustrates the feasibility and safety of FV-EUS–guided FNB for pharyngeal SELs and suggests a wider role for FV-EUS in head and neck disorders.

A 79-year-old man presented with fever and jaundice. Laboratory tests revealed elevated inflammatory markers and hepatobiliary enzymes. Magnetic resonance imaging revealed a 20 × 16 cm giant hepatic cyst compressing the intrahepatic bile ducts. Emergency endoscopic retrograde cholangiopancreatography revealed intrahepatic bile duct dilatation secondary to cystic compression. An endoscopic nasobiliary drainage tube was inserted. After the cholangitis improved, the tube was replaced with a plastic stent. The patient was discharged but was readmitted 11 days later with recurrent fever and loss of appetite. Computed tomography revealed thickening of the cyst wall and internal debris, consistent with an infected hepatic cyst. Given the patient's poor general condition and presence of compressed vessels and bile ducts along the percutaneous puncture route, endoscopic ultrasound-guided cyst drainage (EUS-CD) with nasocystic drainage was performed. After clinical improvement, surgical fenestration was attempted but aborted due to inflammation and friability with bleeding around the endosonographically/EUS-guided created route (ESCR). On day 25 after EUS-CD, conversion to internal trans-ESCR drainage was performed using a 7-Fr, 15-cm double-pigtail stent, and the transpapillary stent was removed because bile duct compression had resolved. The infection recurred 22 days later owing to stent occlusion, requiring stent exchange and additional drainage via ESCR. Finally, three plastic stents were placed, and the patient had no further infection recurrence. After infection control with nasocystic drainage using EUS-CD, multiple stent placements via ESCR can provide safe, effective, and durable treatment for giant infected hepatic cysts that are unsuitable for percutaneous drainage or surgery.

We report a case of massive bleeding from proton pump inhibitor (PPI)-induced fundic gland polyps (FGPs) that regressed after switching to a histamine-2 receptor antagonist (H2RA). A 46-year-old man with antiphospholipid syndrome had been receiving warfarin and lansoprazole for 4 years. Esophagogastroduodenoscopy (EGD) revealed multiple enlarged, edematous FGPs compared to those observed 3 years earlier. One month later, the patient presented with melena, anemia, and transient loss of consciousness. Laboratory data revealed anemia and a prolonged prothrombin time/international normalized ratio (PT-INR). Emergency EGD showed refractory oozing from the FGPs caused by insufflation and water jet stimulation. The bleeding was successfully controlled with vitamin K administration. After PT-INR normalization, no further bleeding occurred, and a follow-up EGD 3 days later showed no bleeding recurrence. We considered that PPI therapy might lead to recurrent bleeding from the FGPs and switched therapy to an H2RA. Follow-up EGD at 2 and 6 months revealed gradual and marked regression of the FGPs. This case demonstrates that PPI-induced FGPs can result in massive bleeding, particularly in patients receiving anticoagulant therapy. Furthermore, FGP regression following the switch to H2RA suggests that H2RA therapy may be an alternative treatment when discontinuation of PPI therapy is not feasible.

Hybrid nerve sheath tumors (HNSTs) are exceedingly rare in the gastrointestinal tract, particularly in the stomach. We describe a case of an enlarging gastric subepithelial lesion (SEL) that was accurately diagnosed and curatively treated by endoscopic full-thickness resection (EFTR). A 50-year-old woman presented with a 10 mm SEL on the posterior wall of the upper gastric curvature. Endoscopic ultrasound (EUS) revealed a low-hypoechoic lesion primarily originating from the third layer with focal, indistinct borders with the muscularis propria. Initial boring biopsy suggested a granular cell tumor based on morphology and SOX10/S100 positivity. Six months later, the lesion had enlarged to 15 mm, and EFTR under general anesthesia with laparoscopic backup was selected to obtain a full-thickness specimen. En bloc resection was successfully achieved, and the defect was completely closed with clips. Histopathological and immunohistochemical examinations revealed biphasic Schwann and perineurial differentiation, confirming a hybrid schwannoma/perineurioma. The postoperative course was uneventful, and no recurrence was observed during the 22-month follow-up. This case highlights the diagnostic value of EFTR for rare neurogenic SELs in which superficial biopsy may be inconclusive.