Takanori Yamada

A 61-year-old man present to us with continued abdominal pain without abdominal tenderness for 1 month. Blood testing showed elevated biliary enzymes and inflammation. Contrast-enhanced computed tomography (CT) revealed thickening of the transverse colon with relatively strong enhancement but no bile duct dilatation. Colonoscopy revealed localized edema and granular mucosa in the transverse colon. Fluoroscopic endoscopy exhibited the absence of haustra. Multiple biopsies were performed, but differentiation between mild inflammation and mucosa-associated lymphoid tissue (MALT) lymphoma was inconclusive. To establish a definitive diagnosis, transgastric endoscopic ultrasound-guided fine needle biopsy of the hypoechoic mass was performed. Histopathological analysis exhibited the proliferation of small-sized lymphocytes. Fluorescence in situ hybridization revealed the characteristic API2-MALT1 translocation of MALT lymphoma. We performed liver biopsy to investigate biliary enzyme elevation. Histopathology confirmed lymphocytic infiltration within Glisson’s capsule. Immunohistochemistry showed positive for CD20 and negative for CD3 and CD5, signifying the infiltration of MALT lymphoma in the liver. Based on these findings, we diagnosed MALT lymphoma, Lugano classification Stage IV. We performed bendamustine–rituximab (BR)-combined therapy. After six courses of BR-combined therapy, colonoscopy revealed improvement in the lead pipe sign and CT revealed disappearance of the mass.

Endoscopic ultrasound (EUS), a well-established diagnostic modality, allows for visualization of previously inaccessible anatomical regions and enables tissue acquisition and therapeutic procedures [1] [2]. In interventional EUS, a curved linear array echoendoscope is first used to visualize an object with a high frequency transducer at the echoendoscope tip. A dedicated needle is then used to puncture the object under ultrasound guidance [3]. If fixation of the high frequency transducer becomes loose and rotates, it becomes difficult to visualize the puncture needle. We describe a case and in vitro studies showing the effect of mechanical failure of an echoendoscope ([Video 1]). A 76-year-old man was referred to our hospital with elevated liver enzyme levels, so an EUS-guided liver biopsy was planned. A curved linear array echoendoscope (GF-UCT260; Olympus Medical Systems Corp., Tokyo, Japan) and 19-gauge Franseen needle (Acquire; Boston Scientific Corporation, Natick, Massachusetts, USA) were used. First, the left liver lobe was visualized under ultrasonographic guidance. The sheath was recognized; however, the needle was obscured ([Fig. 1]). During puncture, the needle was visualized by moving the endoscope. Finally, liver tissue was acquired without complications. After the procedure, fixation of the high frequency transducer was found to be loose and rotated 10° counterclockwise ([Fig. 2]). Subsequent puncture experiments were performed using tofu. The puncture needle was poorly visualized when the high frequency transducer was rotated, but it was well visualized when the rotation was restored to normal ([Fig. 3], [Fig. 4]). The high frequency transducer was firmly fixed when this echoendoscope was purchased, and there were no instances of strong external shock waves. The cause of mechanical failure is unknown but may be due to age-related deterioration. In interventional EUS, loose fixation not only leads to an unsuccessful procedure but can also cause serious complications. Endoscopists should ensure proper fixation of the high frequency transducer before performing interventional EUS. Endoscopy_UCTN_Code_TTT_1AS_2AF Article published online: 29 July 2024 © 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Screening esophagogastroduodenoscopy plays an important role in the early detection of upper gastrointestinal cancer. To provide more opportunities for patients with pancreaticobiliary disease to undergo this screening, we have performed esophagogastroduodenoscopy prior to endoscopic ultrasonography. However, the usefulness of this protocol is not elucidated. This study aimed to investigate the utility of screening esophagogastroduodenoscopy in this protocol in the detection of upper gastrointestinal epithelial neoplasms. The outcomes of screening esophagogastroduodenoscopy performed prior to endoscopic ultrasonography in patients with pancreaticobiliary disease at our hospital between April 2020 and September 2022 were investigated. A logistic regression model was used to identify factors affecting the detection of epithelial neoplasms. Additionally, we compared the detection rate of gastric epithelial neoplasms between screening esophagogastroduodenoscopy performed prior to endoscopic ultrasonography and that performed at our medical checkup center. A total of 615 screening esophagogastroduodenoscopies prior to endoscopic ultrasonography were performed, and 12 (2.0%) epithelial neoplasms were detected, including esophageal lesions (n = 2) and gastric lesions (n = 10). Of these lesions, 75% (9/12) underwent curative endoscopic resection. A multivariate analysis showed that open-type gastric mucosal atrophy (odds ratio, 7.7; 95% confidence interval, 1.5–38.4; p = 0.01) and the use of magnification endoscopy (odds ratio, 7.3; 95% confidence interval, 1.9–27.9; p < 0.01) independently affected the detection of epithelial neoplasms. The detection rate of gastric epithelial neoplasms was significantly higher using this protocol than that in our medical checkup center (1.6% versus 0.2%, p < 0.01). A protocol of screening esophagogastroduodenoscopy prior to endoscopic ultrasonography may be recommended because epithelial neoplasms could be detected at a non-negligible rate.

Background:Gastric cancer screening using esophagogastroduodenoscopy is crucial in areas in which gastric cancer has a high incidence. To provide more opportunities for gastric cancer screening, we have a protocol of sequential esophagogastroduodenoscopy and endoscopic ultrasonography using each dedicated scope for patients with pancreaticobiliary disease; however, the usefulness of this protocol is not elucidated. This study aimed to investigate the utility of screening esophagogastroduodenoscopy in this protocol for the detection of gastric epithelial neoplasms.Methods:We investigated the utility of screening esophagogastroduodenoscopy performed sequentially with endoscopic ultrasonography for patients with pancreaticobiliary disease at our hospital between April 2020 and September 2022 and compared its detection rate for gastric epithelial neoplasms with that of gastric cancer screening at our medical checkup center. Additionally, a logistic regression model was used to identify factors affecting the detection of gastric epithelial neoplasms.Results:A total of 615 screening esophagogastroduodenoscopies were performed sequentially with endoscopic ultrasonography, and 10 (1.6%) gastric epithelial neoplasms were detected: early gastric cancer in 7 and gastric adenoma in 3. The detection rate of gastric epithelial neoplasms in the protocol was higher than that in the medical checkup center (1.6% vs. 0.2% [14/7,763],p<0.01). Additionally, using a magnification endoscope was the only independent factor affecting the detection of gastric epithelial neoplasms in the protocol (odds ratio, 9.53; 95% confidence interval, 1.98–45.90;p<0.01).Conclusions:A protocol of sequential esophagogastroduodenoscopy and endoscopic ultrasonography is recommended to detect gastric epithelial neoplasms. Additionally, magnification endoscopy may facilitate detection in this protocol.

Endoscopic ultrasound (EUS)-guided liver abscess drainage is an alternative method in cases where percutaneous drainage (PCD) is difficult to perform [1] [2]. However, reports on EUS-guided caudate lobe liver abscess drainage remain scarce, with only 12 reported cases [3]. Of these cases, 33 % (4 /12) were treated with a transesophageal approach, which can cause mediastinitis, mediastinal emphysema, and pneumothorax [4] [5]. Herein, we present a case of safe and successful drainage via this method using marking clips and adjusting the scope position. A 50-year-old man with type 2 diabetes mellitus was hospitalized for fever and epigastralgia evolving for 4 days. Computed tomography (CT) revealed a 4.5 × 5.1-cm abscess in the liver caudate lobe ([Fig. 1]). PCD was not performed because of poor visualization on abdominal ultrasonography. After 2 weeks of antibiotic treatment with little improvement, he was referred to our hospital, where EUS-guided caudate lobe liver abscess drainage was performed ([Video 1]). Video 1 Endoscopic ultrasound-guided caudate lobe liver abscess drainage. First, a forward-viewing endoscope was used to mark the esophagogastric junction with a clip so that its location could be determined under fluoroscopy. Subsequently, an echoendoscope was introduced into the stomach. By advancing the scope further from the clip and applying an upward angle, the abscess was successfully visualized from within the stomach. The abscess was punctured using a 19-gauge needle with fluoroscopic confirmation of the marking clip, and a 0.025-inch guidewire was inserted into the abscess cavity. Another 0.035-inch guidewire was placed in the abscess cavity using a double-lumen catheter. After dilation using an electrocautery dilator, a 7-Fr double-pigtail plastic stent and a 6-Fr naso-abscess tube were placed ([Fig. 2]). Klebsiella pneumoniae was cultured from the abscess contents ([Fig. 3]). The nasal tube was removed, and the patient was discharged on day 10 without any complications. The plastic stent was removed 3 months later without liver abscess recurrence. Endoscopy_UCTN_Code_TTT_1AS_2AD Article published online: 06 October 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

A cystic duct remnant stone is a symptom of post-cholecystectomy syndrome (PCS) reported to occur in up to 40 % of patients within 2 days to 25 years after cholecystectomy [1]. Traditionally, surgery has been performed for PCS because endoscopic treatment is challenging [2]. Peroral cholangioscopy (POCS) and electrohydraulic lithotripsy (EHL) are now available for biliary stones, including cystic duct stones, which are difficult to treat with conventional procedures [3] [4] [5]. Here, we report a case of endoscopic removal of a cystic duct remnant stone using POCS, EHL, and steps targeted at its efficient removal. An 80-year-old woman with a history of open cholecystectomy for cholelithiasis 45 years prior was admitted to our hospital owing to abdominal pain and jaundice. Computed tomography revealed a cystic duct remnant stone 2 cm in diameter ([Fig. 1]). The patient underwent endoscopic biliary drainage using a plastic stent for acute cholangitis. Because removal of the cystic duct remnant stone using conventional procedures was unsuccessful, POCS (SpyGlass DS; Boston Scientific, Marlborough, Massachusetts, USA) and EHL were used ([Video 1]). Fragmentation of the cystic duct remnant stone using POCS and EHL was successful; however, stone fragments in the cystic duct could not be directly removed using conventional balloon and basket catheters. Therefore, the following steps were required. First, irrigation with physiological saline while performing EHL flushed the stone fragments from the cystic duct remnant to the common bile duct (CBD), whereupon they were removed. Second, any gross stone fragments remaining in the cystic duct remnant were removed using the SpyGlass Retrieval Basket (Boston Scientific). Finally, remaining stone fragments were powdered using EHL. No adverse events occurred. Magnetic resonance imaging 3 months revealed no residual or recurrent biliary stones ([Fig. 2]). Video 1 Removal of cystic duct remnant stone achieved endoscopically using a peroral cholangioscope and electronic hydraulic lithotripsy. Endoscopy_UCTN_Code_TTT_1AR_2AH Article published online: 25 November 2022 © 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Minimizing radiation exposure time is one of the three principles of radiation safety. However, fluoroscopy is often used unnecessarily when endoscopists are not looking at the fluoroscopy monitor. Unnecessary radiation exposure is due to the complexity of fluoroscopic endoscopy procedures, wherein multiple operators independently view different parts of multiple monitors. These procedures usually need an endoscopist for endoscope maneuvers and one or more assistants for other devices; therefore, a radiologic technologist, who manages radiation exposure, cannot always monitor the line of sight of all operators at once. As limited tools are available to reduce endoscopic radiation exposure time [1], we developed a new eye-tracking fluoroscopy system that informs the radiologic technologist when the operators’ line of sight is directed toward the monitor. It can track the operators’ line of sight and flash a “watching” alert on the detection monitor once a line of sight to the fluoroscopy monitor is detected. This system, jointly developed with NEC Corporation (Tokyo, Japan), was designed to detect remote gaze of operators simultaneously using artificial intelligence (AI)-based face-recognition technology. Radiologic technologists can use this system by attaching an external camera to the fluoroscopy monitor ([Fig. 1]) and connecting the camera to the detection monitor and the AI software. The system could detect the operators’ line of sight to the fluoroscopy monitor with high accuracy. This was demonstrated in an experimental study by three personnel wearing radiation safety glasses and personal protective equipment, who raised their hands only when gazing at the fluoroscopy monitor ([Fig. 2]). The line of sight detected included both deliberate and unconscious gaze by operators. The system worked in real time during endoscopic procedures ([Fig. 3]). Radiation exposure could thus be minimized by detecting line of sight during actual endoscopy ([Video 1]). Video 1 Eye-tracking fluoroscopy system for reducing radiation exposure time during endoscopy. This AI-based eye-tracking system is a promising tool to reduce radiation exposure time of patients and operators during fluoroscopic endoscopy procedures. Endoscopy_UCTN_Code_TTT_1AR_2AK Article published online: 11 November 2022 © 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

For gastric lesions in a patient with a history of breast cancer, it is essential to distinguish between primary gastric cancer and gastric metastasis from breast cancer. However, gastric metastasis from breast cancer often mimics primary linitis plastica, and histological diagnosis may be difficult with conventional endoscopic biopsies. Herein, we describe the case of a 75‐year‐old woman who presented at our hospital with epigastralgia and vomiting. She had a history of mastectomy for carcinoma of the right breast and had received hormone therapy as adjuvant therapy. Computed tomography at arrival showed thickening of the gastric wall at the antrum and peritoneal dissemination. Esophagogastroduodenoscopy showed mucosal swelling of the antrum and stenosis of the pylorus, and histological diagnosis failed with conventional endoscopic biopsies. Endoscopic ultrasound‐guided fine‐needle biopsy using a Franseen needle was performed, and a diagnosis of gastric metastasis from breast cancer was made. She received hormone therapy and chemotherapy after deployment of a metallic stent for gastric outlet obstruction. To the best of our knowledge, this is the first case of gastric metastasis from breast cancer diagnosed using endoscopic ultrasound‐guided fine‐needle biopsy.

Malignant hilar biliary obstruction often requires multiple stents for biliary drainage [1] [2]. However, deploying three or more self-expandable metal stents (SEMSs) is technically challenging [3]. The recently launched, novel uncovered SEMS with slim delivery system (Niti-S Large Cell SR Slim delivery; TaeWoong Medical, Seoul, South Korea) may be combined with a 6-mm balloon catheter (REN biliary dilation catheter; KANEKA, Osaka, Japan) to facilitate the deployment of multiple SEMSs [4]. Here, we report a successful endoscopic four-branched deployment of SEMSs using the stent-in-stent (SIS) method. A 66-year-old man with metastatic hilar cholangiocarcinoma, who had been undergoing chemotherapy, was admitted to our hospital with acute cholangitis. Initially, 7 months previously, two plastic stents had been deployed for malignant hilar obstruction of Bismuth type 4 in the B2 and B8 bile duct segments above the sphincter of Oddi. However, owing to recurrent cholangitis and a liver abscess, a total of four plastic stents were deployed 4 months later in B2, B5, B6, and B8 ([Fig. 1]). A computed tomography scan on admission showed dysfunctional plastic stents and deterioration of his cancer ([Fig. 2]). We attempted to deploy four SEMSs using the SIS method ([Video 1]). First, after removing the plastic stents, we deployed the first and second SEMSs in B6 and B2 using the SIS method. After dilating the mesh of the SEMSs using a balloon catheter, we deployed the third SEMS in B8 using the SIS method. Finally, an attempt was made to deploy a SEMS in B5, but the catheter could not be passed through the mesh of the SEMS. Therefore, a balloon catheter was used to dilate the lumen and mesh of the SEMSs, and the fourth SEMS was then successfully deployed in B5 using the SIS method ([Fig. 3]). There were no adverse events such as stent occlusion during the 2 months before the patient’s death, which was due to his primary disease. Video 1 Successful endoscopic four-branched deployment using the stent-in-stent method for malignant hilar biliary obstruction. Endoscopy_UCTN_Code_TTT_1AR_2AZ Publication Date: 01 October 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Post-ERCP pancreatitis (PEP) after self-expandable metallic stent (SEMS) insertion across the papilla of Vater is an important adverse event that affects the patient’s quality of life (QOL). We exa...