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To the Editor,

Kudo and colleagues¹ clearly demonstrated that intravenous propofol anesthesia significantly shortened procedure time in pediatric endoscopy, with no adverse events observed. Subsequent to the revision of Japanese guidelines for endoscopic sedation,² gradual adoption of propofol sedation in adult endoscopic procedures is noted. Importantly, however, this guideline explicitly excludes pediatric populations. Additionally, this guideline refrains from explicitly stating whether non-anesthesiologists can safely administer propofol sedation in endoscopy units. Gastroenterologists should understand that propofol is not recommended for anesthetic induction below the age of 3 years or for anesthetic maintenance below 2 months of age. As discussed in this paper, propofol is contraindicated for pediatric intensive care unit sedation due to the risk of propofol infusion syndrome; thus, excessive use should be avoided. Actually, our hospital witnessed an accidental intensive care unit death of a pediatric patient sedated with propofol.

Our concern stems from the fact that current evidence regarding safe propofol sedation for endoscopy is based predominantly on international reports. The Japanese medical environment differs significantly from those abroad. While anesthesiologists in many other countries routinely administer sedation, the current structure and resource allocation in Japan makes it practically infeasible to have anesthesiologists permanently stationed in endoscopy units. Unlike benzodiazepines, propofol has a narrow pharmacological range between states of sedation with maintained respiration and that of general anesthesia where spontaneous breathing ceases, making it prone to easily induce over-sedation. Therefore, the guideline also emphasizes the use of various devices supporting safe propofol administration; consequently, continuous administration via a target-controlled infusion pump is recommended, and the importance of capnography and/or electroencephalography is stressed (in Japan, widespread adoption of this monitoring in pediatric patients is insufficient). The methodology in Kudo et al.¹ did not address these recommendations.

Given the aforementioned precautions for propofol use in pediatric patients, endoscopic sedation in children using propofol warrants more careful consideration, prioritizing safety.

None.

- Approval of the research protocol by an Institutional Reviewer Board: N/A.

- Informed consent: N/A.

- Registry and the Registration No. of the study/trial: N/A.

- Animal studies: N/A.

We encountered a case of a large hematoma developing with perforation shortly after a cold snare polypectomy for a colorectal adenoma. The patient underwent cold snare polypectomy for a 3-mm type Is lesion in the transverse colon at another facility. Two hours later, she visited the emergency room due to abdominal pain. Contrast-enhanced computed tomography revealed a 70 mm, high-intensity mass in the transverse colon with contrast extravasation. We attempted transcatheter arterial embolization to stop the bleeding. Several hours later, the anemia had not worsened, but the severe abdominal pain persisted. Urgent laparoscopic right hemicolectomy was performed due to the possibility of gastrointestinal perforation. The surgery was successfully completed. Pathology reports confirmed the presence of an intramural hematoma in the proximal transverse colon with hemorrhagic infiltration of all layers, along with extensive ischemic changes. A perforation was identified in this area, with mucosal defects observed near the hole, possibly due to cold snare polypectomy.

Gastrointestinal tract involvement in Langerhans cell histiocytosis (LCH) is extremely rare, with limited documentation of endoscopic manifestations. We report a 19-month-old girl who presented with repeated diarrhea and bloody stools, accompanied by recurrent pulmonary infections, anemia, hypoproteinemia, thrombocytopenia, coagulopathy, and hepatosplenomegaly with lymphadenopathy. Initial treatment with antibacterial agents, mesalazine, thalidomide, and prednisone led to temporary improvement; however, the symptoms repeatedly relapsed. She underwent three digestive endoscopies, but until the third endoscopy, a definitive diagnosis of Langerhans cell histiocytosis was established through biopsy. While upper gastrointestinal tract findings were not significant, notable changes were observed in the colorectal region. A colonoscopy revealed progression from erythema to diffuse hyperemia and edema, with erythema, erosion, and superficial ulcers extending into the distal ileal mucosa. Genetic analysis identified a BRAF-V600E mutation. Following treatment with chemotherapy (vincristine and prednisone) and the BRAF inhibitor dabrafenib, the patient demonstrated significant clinical improvement within days. At the 1-year follow-up, the patient had normal bowel movements and a weight gain of 2.5 kg. Early gastrointestinal endoscopy with multiple biopsies in suspected children can facilitate early detection. Dabrafenib is a viable treatment option for Langerhans cell histiocytosis.

The definitive diagnosis of patients with indeterminate biliary strictures remains challenging. Probe-based confocal laser endomicroscopy (pCLE) provides real-time histological assessment of bile duct tissues. Since no previous studies have evaluated the efficacy of pCLE under direct cholangioscopic visualization for biliary strictures that cannot be definitively diagnosed through endoscopic retrograde cholangiopancreatography using fluoroscopy, we prospectively assessed the feasibility and safety of this procedure in three cases. pCLE findings were obtained in three cases, providing accurate diagnoses. Additionally, no adverse event was reported. pCLE under direct cholangioscopic visualization for indeterminate biliary strictures might be feasible and safe, even though these strictures were not previously diagnosed using endoscopic retrograde cholangiopancreatography. Further studies with more cases are warranted to clarify the effectiveness of pCLE under direct cholangioscopic visualization.

The patient was a woman in her 70s with multiple large biliary stones. Lithotripsy was attempted after endoscopic papillary large balloon dilatation. During balloon dilation, inflator resistance, and body movement due to patient pain were observed, and maximum pressure was required for the disappearance of the balloon waist. A bile duct perforation was observed when the balloon was deflated. Computed tomography after endoscopic retrograde cholangiopancreatography showed free air from the duodenal peritoneum to the right retroperitoneum. The patient was conservatively treated with nasobiliary drainage. Endoscopic large balloon dilatation is useful for large bile duct stones that are difficult to remove using endoscopic sphincterotomy alone or endoscopic papillary balloon dilation. Perforation is a potentially fatal adverse event; therefore, imaging of the intrapancreatic bile ducts should be performed before endoscopic retrograde cholangiopancreatography and attention should be paid to the balloon dilation method.

We report a case of a man who was diagnosed with superficial hypopharyngeal cancer and recurrence of renal cell carcinoma in the duodenum, liver, and gluteus medius muscle simultaneously. He underwent endoscopic submucosal dissection for hypopharyngeal cancer in parallel with systemic immunotherapy for recurrent renal cell carcinoma, resulting in completely overcoming both malignancies. Endoscopic submucosal dissection is less invasive and can be performed in a shorter duration for treating superficial hypopharyngeal cancer compared with other treatment options, such as radiation therapy, chemotherapy, and surgery. Additionally, endoscopic submucosal carcinoma is adequately effective in controlling local lesions and has a satisfactorily good prognosis.