Norio Fukami

Submucosal lesions of the esophagus and stomach are commonly discovered as incidental findings during routine endoscopy. These lesions arise from varying layers of the gastrointestinal wall, primarily from the submucosa or the muscularis propria, and can range from benign to malignant. This review provides an overview of common submucosal lesions including gastrointestinal stromal tumors (GIST), leiomyomas, duplication cysts, varices, glomus tumors, lipomas, granular cell tumors, neuroendocrine tumors, pancreatic rest, and schwannomas. We focus on their clinical presentation, endoscopic characteristics, radiologic features, and histopathologic findings to aid in diagnosis.

INTRODUCTION: The study aimed to develop consensus recommendations for the safe and appropriate use of liquid nitrogen spray cryotherapy in Barrett's esophagus and esophageal cancer. METHODS: Statements were initially formulated and grouped into categories of indications, training, preprocedure, intraprocedure, and postprocedure recommendations, frequency/timing of repeat procedures, and contraindications. Two investigators assessed the strength of the evidence for each statement using Grading of Recommendations Assessment, Development, and Evaluation methodology. Nineteen experts were invited to participate in a modified Delphi process. For statements that received >80% agreement, minor iterative edits were performed until there was unanimous consensus. If a threshold of 80% agreement was not reached, the statement was modified based on feedback and included in the next Delphi round. Statements were rejected if no consensus was reached after 3 rounds. RESULTS: After 3 Delphi rounds, 41 of 42 statements were accepted either in their original version (n = 11) or after modification based on expert input (n = 30). DISCUSSION: Through a modified Delphi process, we developed expert and evidence-based consensus recommendations to guide safe and appropriate use of liquid nitrogen spray cryotherapy in Barrett's esophagus and esophageal cancer.

Background and objective: Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for managing malignant biliary obstruction (MBO), but it is challenging in patients with surgically altered anatomy (SAA). EUS-guided hepaticogastrostomy (EUS-HGS) and enteroscopy-assisted ERCP are alternative techniques, but their comparative efficacy and safety in this population are not well-researched. Herein, we evaluated the outcomes of EUS-HGS versus single-balloon–assisted enteroscopy ERCP (SBE-ERCP) in MBO patients with SAA. Patients and methods: This retrospective study included 70 patients with MBO who underwent EUS-HGS (n = 29) or SBE-ERCP (n = 41) at a single center between April 2015 and June 2024. Data on the patient characteristics, procedure details, time to recurrent biliary obstruction (TRBO), and adverse events (AEs) were analyzed. Results: The EUS-HGS group showed a higher technical success rate (100% vs. 68%, P = 0.002), shorter procedure time (23 vs. 50 min, P < 0.001), and longer TRBO (251 vs. 103 d, P = 0.020) as compared with the SBE-ERCP group. Subgroup analysis revealed that pancreatobiliary cancer and SBE-ERCP were significantly associated with a shorter TRBO. When stratified by stent type, the median TRBO in the SBE-ERCP with PS group was 49 days, serving as the reference. In comparison, the median TRBO was 140 days in the SBE-ERCP with the self-expandable metallic stent group (hazard ratio [HR], 0.46; P = 0.181), 127 days in the EUS-HGS with PS group (HR, 0.38; P = 0.055), and 701 days in the EUS-HGS with the self-expandable metallic stent group (HR, 0.13; P = 0.014). The overall incidence of AEs was comparable between the 2 groups (20.6% vs. 17.1%), and there were no severe AEs. Regarding reintervention, there was no significant difference in technical success rate and procedure time between EUS-HGS and SBE-ERCP. Conclusion: EUS-HGS was associated with a superior technical success rate, shorter procedure time, and longer stent patency, without an increased risk of AEs, as compared with SBE-ERCP. Thus, EUS-HGS should be appropriate for managing MBO patients with SAA.

INTRODUCTION: Endoscopic eradication therapy (EET) is standard of care for T1a esophageal adenocarcinoma (EAC). However, data on outcomes in high-risk T1a EAC are limited. We assessed and compared outcomes after EET of low-risk and high-risk T1a EAC, including intraluminal EAC recurrence, extraesophageal metastases, and overall survival. METHODS: Patients who underwent EET for T1a EAC at 3 referral Barrett's esophagus endotherapy units between 1996 and 2022 were included. Patients with submucosal invasion, positive deep margins, or metastases at initial diagnosis were excluded. High-risk T1a EAC was defined as T1a EAC with poor differentiation and/or lymphovascular invasion, with low-risk disease being defined without these features. All pathology was systematically assessed by expert gastrointestinal pathologists. Baseline and follow-up endoscopy and pathology data were abstracted. Time-to-event analyses were performed to compare outcomes between groups. RESULTS: One hundred eighty-eight patients with T1a EAC were included (high risk, n = 45; low risk, n = 143) with a median age of 70 years, and 84% were men. Groups were comparable for age, sex, Barrett's esophagus length, lesion size, and EET technique. Rates of delayed extraesophageal metastases (11.1% vs 1.4%) were significantly higher in the high-risk group (P = 0.02). There was no significant difference in the rates of intraluminal EAC recurrence (P = 0.79) and overall survival (P = 0.73) between the 2 groups. DISCUSSION: Patients with high-risk T1a EAC undergoing successful EET had a substantially higher rate of extraesophageal metastases compared with those with low-risk T1a EAC on long-term follow-up. These data should be factored into discussions with patients while selecting treatment approaches. Additional prospective data in this area are critical.