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Endoscopic retrograde cholangiopancreatography (ERCP) is the standard procedure for biliary drainage; however, access can be challenging in patients with altered anatomy or tumor-related distortion. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a common alternative, yet it is not always feasible, particularly in patients with prior hepatic resection or severe gastrointestinal deformation. A 67-year-old woman developed obstructive jaundice due to hilar biliary stricture secondary to peritoneal dissemination following colorectal cancer surgery. Initial ERCP achieved side-by-side placement of multi-hole self-expandable metal stents (MHSEMSs), resulting in effective drainage. At recurrence of cholangitis, repeat ERCP failed because of anatomical distortion, and EUS-BD was not feasible due to the patient's prior left hepatectomy. We therefore employed a novel technique: a double-balloon enteroscope overtube was advanced to the duodenum, and a side hole was created 10 cm distal to the insertion port. An ultrathin endoscope was inserted through this side hole, retroflexed in the duodenum, and successfully accessed the papilla. The previously placed MHSEMSs were removed, and new MHSEMSs were deployed using a stent-in-stent method. The patient's cholangitis and associated liver abscesses improved, allowing continuation of systemic chemotherapy. This case demonstrates a novel overtube-assisted ultrathin endoscope technique. The combination of thin delivery systems and an overtube modification may provide a valuable alternative when both conventional ERCP and EUS-BD are not feasible.

Placement of percutaneous endoscopic gastrostomy (PEG) is generally safe and well-tolerated. Transhepatic insertion of PEG tubes is an extremely rare but serious complication. Optimal management strategies for safe removal of PEG tubes remain unclear. A 70-year-old male with hypopharyngeal cancer underwent PEG placement prior to chemoradiotherapy. The patient experienced mild puncture site pain. Progressive elevation of inflammatory markers prompted computed tomography (CT) imaging on postoperative day 2, which revealed inadvertent transhepatic catheter placement through the lateral segment. Minimally invasive removal was prioritized over surgical management to enable continuation of chemoradiotherapy. To prevent bleeding and biliary leakage, gelatin sponge (GS) was embolized for tract closure. A pull-through technique was established for emergency tract access if massive bleeding occurred. After removal of the tube, embolic material was injected under fluoroscopic and endoscopic guidance. The gastric entry site was closed with endoscopic clips. Serial CT showed no bleeding or biliary leakage, and the patient recovered uneventfully and completed chemoradiotherapy without treatment delays. Embolization of GS represents a safe and effective technique for the removal of a transhepatic PEG tube. This minimally invasive approach successfully prevented serious complications in this rare case of PEG-related hepatic injury.

Kaposi Sarcoma (KS) is a rare vascular tumor linked to Human Herpesvirus-8 (HHV-8) infection, most often affecting immunocompromised patients with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS). Gastrointestinal KS (GI-KS) is frequently underdiagnosed, particularly in resource-limited settings, and may present with nonspecific symptoms. We describe a 52-year-old HIV-positive male with advanced immunosuppression (CD4 count: 34 cells/µL, viral load: 236,670 copies/mL) who presented with abdominal pain, weight loss, and violaceous cutaneous lesions. Upper GI endoscopy revealed multiple reddish nodular gastric lesions with a distinctive “lobster-like” morphology. Histopathology showed abnormal vascular proliferation, with endothelial cells positive for CD34 and HHV-8, confirming gastric KS. Colonoscopy was unremarkable. The patient received HAART only, without systemic chemotherapy, and refused further treatment and follow-up. The coexistence of gastric and cutaneous KS in this patient reflects disseminated disease and highlights the importance of early endoscopic evaluation in HIV-infected individuals with unexplained GI complaints. This case adds to the limited literature on gastric KS in the Middle East and documents an unusual endoscopic appearance that may aid in earlier recognition. To our knowledge, this is the first report of a gastric KS lesion with a novel “lobster-like” appearance. This appearance likely reflects the tumor's vascular origin, producing bilateral, claw-shaped mucosal elevations due to submucosal vascular proliferation. Greater awareness of such presentations can facilitate timely diagnosis, multidisciplinary management, and improved outcomes in advanced HIV.

The management of complex gastrointestinal defects (CGDs), such as fistulas, leaks, and anastomotic dehiscence, remains challenging. Over-the-scope suturing (OTSS) systems provide effective closure, but their application is limited to specific anatomical sites. The X-Tack through-the-scope suturing (TTSS) system offers a minimally invasive alternative for CGD closure without requiring scope withdrawal. This case series evaluated patients who underwent TTSS closure for CGDs ≤25 mm at our center. All patients were assessed through computed tomography and multidisciplinary board discussion before endoscopic treatment. Endoscopic closure was performed using the X-Tack system, applying a figure-of-8 or zig-zag pattern depending on defect characteristics. Follow-up included clinical and laboratory assessments at seven days and during long-term observation. Thirteen patients underwent TTSS closure, achieving a 100% technical success rate. Clinical and laboratory remission at seven days was observed in 76.9% of cases, with a sustained clinical remission in 76.9% after a median follow-up of 2.5 months. The procedure was effective even in challenging anatomical locations, including post-surgical anastomotic leaks and narrow lumens. TTSS using the X-Tack system is a safe and effective approach for small CGD closure, particularly in difficult anatomical sites.

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with a lumen-apposing metallic stent is advised for frail patients with acute cholecystitis. However, concerns remain about severe tissue reactions and potential negative impacts on subsequent surgery. EUS-GBD using a double-pigtail plastic stent (DPPS) is an alternative for these patients. However, multiple steps harbor bile or air leaking from the anastomosis site. Some DPPS systems comprise an inner sheath that mounts a DPPS and a delivery pusher catheter. This DPPS system gains a lavage function, similar to a long plastic irrigation tube, when the inner sheath is retracted to the “halfway back position” within the DPPS. This single-arm retrospective study reviewed the active gallbladder lavage technique using this “halfway back position” of the DPPS system during EUS-GBD for patients with acute cholecystitis who left the option of laparoscopic cholecystectomy (Lap-C) as a final option, depending on clinical and performance status recovery. The technical success rate was 97.3% (36/37). The clinical success rate among those with technical success was 100% (36/36). The median total duration was 25 min 7 s, which included a lavage duration of 8 min 18 s. The volume of lavage was 40 mL, and the number of attempts was two. The length of the anastomosis measured using computed tomography was 11.6 mm. No adverse events were reported. Nine patients (25.0%) were scheduled for elective Lap-C, and none required conversion to open surgery. The active gallbladder lavage technique using the DPPS system during EUS-GBD was both feasible and acceptable.

Metastasis of lung cancer to the small intestine is rare and often diagnosed only after life-threatening complications such as perforation or obstruction. We report a case of small intestinal metastasis from pulmonary large cell carcinoma, diagnosed using balloon-assisted endoscopy (BAE) performed for obscure gastrointestinal bleeding (OGIB). A 73-year-old male patient previously underwent right upper lung lobectomy for stage IA1 large cell carcinoma. At 4 months postoperatively, he presented with melena and anemia. Upper and lower endoscopy and computed tomography failed to identify the bleeding source, prompting capsule endoscopy (CE), which revealed a jejunal ulcer. Subsequent BAE revealed an ulcerative lesion with submucosal tumor-like elevated margins. Histopathological examination of the biopsy specimen showed proliferation of atypical cells with large nuclei, morphologically consistent with the previously diagnosed lung carcinoma. Considering the patient's good performance status and the presence of a solitary lesion, laparoscopic small bowel resection was performed. Histopathological findings of the resected small bowel specimen were consistent with the primary pulmonary lesion. The patient received postoperative chemotherapy and has remained recurrence-free for 1 year. This case underscores the significance of CE and BAE in evaluating OGIB, particularly in patients with a history of lung cancer. Early endoscopic diagnosis may facilitate timely surgical intervention and enhance patient outcomes.