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Background/Aims Endoscopic ultrasound-guided tissue acquisition (EUS-TA) using Franseen needles is reportedly useful for its high diagnostic yield. This study compared the diagnostic yield and puncturing ability of EUS-TA using 22-gauge cobalt-chromium (CO-Cr) needles with those of stainless-steel Franseen needles in patients with solid pancreatic lesions. Methods Outcomes were compared between the 22-gauge Co-Cr Franseen needle (December 2019 to November 2020; group C) and stainless-steel needle (November 2020 to May 2022; group S). Results A total of 155 patients (group C, 75; group S, 80) were eligible. The diagnostic accuracy was 92.0% in group C and 96.3% in group S with no significant intergroup differences (p=0.32). The rate of change in the operator (from training fellows to experts) was 20.0% (15/75) in group C and 7.5% (6/80) in group S. Stainless-steel Franseen needles showed less inter-operator difference than Co-Cr needles (p=0.03). Conclusions Both Co-Cr and stainless-steel Franseen needles showed high diagnostic ability. Stainless-steel Franseen needles are soft and flexible; therefore, the range of puncture angles can be widely adjusted, making them suitable for training fellows to complete the procedure.

Background and Aims: Over-the-scope clips (OTSCs) are used for treating gastrointestinal perforations, postoperative anastomotic leakages, and mucosal defect closure after endoscopic resections. However, OTSCs are expensive and associated with fatal complications; therefore, proper OTSC usage is necessary. Criteria of OTSC use for mucosal defect closure after duodenal endoscopic submucosal dissection (ESD) are scarce. We examined closure outcomes with OTSCs and conventional clips in patients undergoing duodenal ESD, analyzed the resected specimen area, estimated the preoperative size of tumors treated with each method, and attempted to clarify the criteria for the use of OTSCs vs conventional clips. Methods: Endoscopic resection was performed for 133 superficial duodenal epithelial tumors from April 2017 to February 2022. Complete closure of mucosal defects after duodenal ESD was attempted for 82 superficial non-ampullary duodenal epithelial tumors, divided into OTSC and control (conventional clips used) groups. Closure outcomes were analyzed. Results: The overall rate of complete mucosal defect closure in both groups was 98.8%. Significant between-group differences existed in the median estimated tumor size and median resected specimen area. Conclusion: Conventional clips work well for mucosal defects ≤18 mm after duodenal ESD, but for those >18 mm, a combination of OTSCs may be considered.

Abstract Objectives Understanding the exact morphology of the bile duct opening is important for determining the success of bile duct cannulation. Texture and color enhancement imaging (TXI) has been reported to enhance slight changes in color tone and structure that are difficult to see with white light imaging. This study investigated whether TXI mode1 could improve papillary recognition by trainees inexperienced in endoscopic retrograde cholangiopancreatography. Methods We included 31 patients with naive papilla of Vater at a single institution in the study. Trainee endoscopists (n = 4) evaluated and identified the papilla according to the Inomata classification using white light imaging and TXI. The degree of agreement with the evaluation of supervising physicians (n = 4) was examined using the McNemar test. Results In the trainee group, the kappa coefficient agreements were κ = 0.346 and κ = 0.754 for white light imaging and TXI, respectively. When further evaluated, the separate and septal types of papilla groups showed an increased concordance rate in one of the four trainees (76.67%–96.67%, p = 0.031, respectively). Moreover, comparison for two‐group evaluation showed an increased kappa coefficient in two of four trainees (0.34–0.92, p = 0.010, 0.45–0.92, p = 0.024). Conclusions Observation of the duodenal papilla using TXI improved papillary differentiation and suggested the potential of TXI as a clinical tool. Further study of this method is necessary; it is expected to help reduce cannulation time and the incidence of pancreatitis.

Abstract Objectives There is no unanimity regarding the most appropriate needle to use for an endoscopic ultrasound‐guided fine‐needle biopsy (EUS‐FNB). To date, new types of FNB needles have been designed, including the Fork‐tip and Franseen needles. This study primarily aimed to compare the diagnostic accuracy and histological quality between the use of the Franseen and Fork‐tip needles in EUS‐FNB for solid pancreatic lesions. Materials and methods We retrospectively analyzed 147 patients at our center for solid pancreatic lesions, 75 of whom underwent EUS‐FNB using a 22‐G Franseen needle, and 72 using a 22‐G Fork‐tip needle, from December 2019 to September 2021. The present study conducted a propensity‐matched analysis and confounder adjustment. Results The diagnostic accuracy of the Fork‐tip group (93.3%, 42/45) was the same as that of the Franseen group. For the core tissue and blood scores, no significant difference was observed (p = 0.58, 0.25) between the two groups. The rate of changes in the operator from that of a trainee to an expert was less in the Fork‐tip group (4.4%, 2/45) than in the Franseen group (15.6%, 7/45), but not significantly different (p = 0.16). Conclusions In both groups, the diagnostic accuracy and histological quality were not significantly different. Additionally, there were no significant differences in the rate of operator changes. As both needles are useful, the choice of using either of them is equally good.

Abstract Gel immersion endoscopy (GIE) has gained prominence for securing a good visual field. Traditionally, OS‐1 jelly (Otsuka Pharmaceutical Factory) has been used for GIE. However, due to the presence of electrolytes, it is unsuitable for endoscopic hemostasis using a monopolar device. Therefore, VISCOCLEAR (Otsuka Pharmaceutical Factory), a new gel that does not contain electrolytes, has been developed. Moreover, unlike water or saline, VISCOCLEAR does not readily mix with blood, making it effective in visualizing gastrointestinal bleeding. We report two cases in which GIE was performed using a novel gel injection method.

Esophageal endoscopic submucosal dissection (ESD) of tumors located on the gravity side is technically challenging. Given that gel immersion ESD (GIESD) is performed by immersing lesions in gel, we hypothesized that it could be used to eliminate the disadvantage associated with submerging the gravity side. Here, we performed GIESD using VISCOCLEAR for superficial esophageal cancer on the gravity side of the esophagus, with monopolar devices. This study aimed to evaluate the short-term outcomes of GIESD for superficial esophageal cancer. Fifteen patients with 16 superficial esophageal cancers underwent GIESD by a single operator, and 13 cases were evaluated. All patients were male, and GIESD was performed in the middle (12/13, 92.3 %) and lower (1/13, 7.7 %) thoracic esophagus. The lesions were located on the left (7/13, 53.8 %), posterior (5/13, 38.5 %), and right (1/13, 7.7 %) esophageal walls. The median procedure time was 27 minutes (interquartile range [IQR], 14–68), and the median dissection speed was 20 mm2/min (IQR, 14–25.7). The median amount of gel used was 400 mL (IQR, 360–580), and no gel-related adverse events were observed. The median total dose of midazolam was 3 mg (IQR, 2–5). GIESD was completed with en bloc and R0 resections achieved in 100 % of the 13 cases. Delayed adverse events, such as bleeding or perforation, did not occur (0/13, 0 %).

Abstract Endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for pancreatobiliary diseases require advanced techniques. We usually use an oblique‐viewing endoscope in such procedures. Sometimes, tumor invasion causes gastrointestinal strictures. Crossing a stricture using an oblique‐viewing endoscope is more difficult than using a forward‐viewing scope. Therefore, the frequency of scope perforation is higher than other endoscopic procedures. Although surgical repair for gastrointestinal perforations caused by endoscopes has been performed, patients with pancreatobiliary diseases are often elderly and in poor general condition; therefore, patients are hesitant to undergo surgical treatments. Recently, the usefulness of over‐the‐scope clipping (OTSC) as a minimally invasive rescue method has also been reported. In this study, we report cases of successful endoscopic closure using OTSC for gastrointestinal perforations caused by endoscopes in ERCP and EUS‐related procedures. After those procedures, all cases showed no abnormalities in blood tests or symptoms, and emergency surgery was successfully avoided. Thus, endoscopic closure using OTSC for pancreatobiliary endoscopy‐related gastrointestinal perforations is safe and effective. However, OTSC requires some expertise. A good assessment of defect size and careful insertion of the scope using OTSC attached to the upper esophagus are needed to avoid clip migration or disinsertion and esophageal tears. Therefore, endoscopic closure using OTSC could be the first choice of treatment for pancreatobiliary endoscopy‐related gastrointestinal perforations. We should be familiar with its indication and perform it carefully and rapidly.

Background and study aims Endoscopic resection of duodenal neuroendocrine tumors (DNETs) remains controversial, and its indications are still unclear. This study aimed to evaluate short-term outcomes of a newly developed endoscopic muscularis resection (EMR) method that utilizes an over-the-scope clip (OTSC), termed EMRO, for treating DNETs. Patients and methods In total, 13 consecutive patients with 14 small (≤ 10 mm) DNETs who underwent EMRO from September 2017 to March 2020 were retrospectively enrolled. EMRO was performed by a single experienced endoscopist. Patients’ characteristics and treatment outcomes were assessed. Results The En bloc and R0 resection rates were 100 % (14/14) and 92.9 % (13/14), respectively. The median pathological resected specimen size was 10 mm, with a median pathological resected tumor size of 6 mm. During the EMRO procedure, there was no occurrence of misplacement of the OTSC to the target lesion. With respect to the pathological resection depth, nine cases (64.3 %) and five cases (35.7 %) were categorized as deep submucosal resection and muscularis resection, respectively, whereas no case was categorized as full-thickness resection. There were no intraoperative or delayed perforations. However, delayed bleeding occurred in two cases. At a median follow-up of 12 months (range 7–36) after EMRO, there was no incidence of local recurrence. At the first follow-up endoscopy performed at 6 months after EMRO, the OTSC was retained in place in two of 14 DNETs (14.3 %). Conclusions EMRO can be performed safely, by an experienced endoscopist, for small (≤ 10 mm) DNETs.

Background. Accurate diagnosis of benign and malignant lymphadenopathy is important for determining the appropriate treatment and prognosis. This study evaluated the diagnostic accuracy and usefulness of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with a conventional needle compared to endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) with a Franseen needle for diagnosing lymphadenopathy. Methods. Patients who underwent EUS-FNA or EUS-FNB for mediastinal or abdominal lymphadenopathy between July 2013 and August 2020 were enrolled in the study. The outcomes between EUS-FNA patients (July 2013 to January 2017; 22-gauge conventional needle; Group A) and EUS-FNB patients (February 2017 to August 2020; 22-gauge Franseen needle; Group B) were compared. Results. A total of 154 patients (Group A: 83; Group B: 71) were analyzed. The diagnostic accuracy (differentiating between malignant and benign lesions) was 88.0% (95% confidence interval [CI], 79.2–93.3%) in Group A and 95.8% (95% CI, 88.3–98.8%) in Group B. Group B had high diagnostic accuracy, but there was no difference between the groups (p=0.14). Group B had significantly fewer passes (median 2, interquartile range (IQR): 2-4) than Group A (median 3, IQR: 3-4) (p

Background. The accurate diagnosis of biliary strictures remains problematic. The aim of the present study was to prospectively evaluate the clinical utility of probe-based confocal laser endomicroscopy (pCLE) under the direct view of peroral cholangioscopy (POCS) for the diagnosis of biliary strictures. Methods. Consecutive patients with biliary strictures were included. We investigated sensitivity, specificity, and accuracy to diagnose malignancy for (1) ERCP alone, (2) POCS, (3) pCLE under the direct view of POCS, and (4) tissue sampling under the direct view of POCS. Results. A total of 30 patients (17 with malignant lesions) were prospectively enrolled. (1) ERCP alone showed 88.2% sensitivity, 46.2% specificity, and 70% (95% confidence interval (CI), 52.1%–83.3%) accuracy. (2) POCS showed 100% sensitivity, 76.9% specificity, and 90% (95% CI, 74.4%–96.5%) accuracy. (3) pCLE under the direct view of POCS showed 94.1% sensitivity, 92.3% specificity, and 93.3% (95% CI, 78.7%–98.8%) accuracy. (4) Tissue sampling under the direct view of POCS showed 82.4% sensitivity, 100% specificity, and 90% (95% CI, 74.4%–96.5%) accuracy. Conclusions. pCLE under the direct view of POCS provided highly accurate and sensitive characterization of biliary strictures and showed the potential for more diagnostic reliability and reduction of delays in diagnosis. This trial was registered at UMIN (registration number: UMIN000033801).

Background and study aims This study aimed to investigate the diagnostic accuracy and utility of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) performed using a Franseen needle on solid pancreatic lesions. Patients and methods This study included 132 consecutive lesions sampled by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) using a 22-G conventional needle and 95 consecutive lesions evaluated by EUS-FNB using a 22-G Franseen needle to evaluate solid pancreatic lesions at our medical center between July 2013 and November 2018. We used propensity-matched analysis with adjustment for confounders. Patient data were analyzed retrospectively. Results Diagnostic accuracy was higher in the Franseen needle group (Group F; 91.6 %, 87 /95) than in the conventional needle group (Group C; 86.3 %, 82 /95), showing no significant difference (P = 0.36). In Group F, diagnostic accuracies for pancreatic head lesions and lesions sampled by transduodenal puncture were 98.0 % (48/49) and 97.9 % (46/47), respectively. These values were significantly higher than values in Group C (P = 0.013, 0.01). Group F displayed a significantly lower number of punctures. In terms of differentiating benign from malignant lesions, Group C showed 85.1 % sensitivity (74/87), 100 % specificity (8/8), 100 % positive predictive value (74/74), and 38.1 % negative predictive value (8/21), compared to values of 90.1 % (73/81), 100 % (14/14), 100 % (73/73), and 63.6 % (14/22), respectively, in Group F. Sensitivity and negative predictive value were better in Group F. Conclusions Franseen needles for EUS-FNB of solid pancreatic lesions offer similar puncture performance at different lesion sites while requiring fewer punctures than conventional needles.

We reported a 95‐year‐old man with cholangitis who underwent Billroth‐I gastrectomy. He was diagnosed with situs inversus viscerum and ERCP was performed. A stable field of view could not be secured due to anatomical factors (Billroth‐I gastrectomy) and strong respiratory variations. However, pancreatic duct cannulation was possible. A pancreatic guidewire was placed to achieve selective biliary cannulation. This stabilized the field of view. The catheter was inserted on the right side of the guidewire. Cannulation to the 1 o'clock direction achieved biliary cannulation. Intended procedure was completed safely in the present case.

Background and study aims: Despite the clinical advantages of colorectal endoscopic submucosal dissection (ESD), an effective training system, especially for Western endoscopists, has been challenging to establish. Herein, we propose a novel training program using ex vivo animal models and evaluate the learning curve of colorectal ESD trainees without gastric ESD experience. Patients and methods: A total of 80 colorectal lesions were prospectively collected and removed by two novice operators. Before human ESD procedures, they received ESD training using an ex vivo porcine “proximal colon” model, which simulates a lumen with many folds and flexions. To assess the validity of our training system, the self-completion and en bloc R0 resection rates, the operation time, and prevalence of complications were compared between the first and latter period. Moreover the factors associated with prolonged operation time were evaluated. Results: The overall rates of self-completion and en bloc R0 resection were 98 % (78/80) and 100 % (80/80), respectively. The operation time during the first period was significantly longer than that during the latter period (86 ± 50 minutes vs. 60 ± 36 minutes, P = 0.01). Regarding complications, only two cases of perforations and delayed hemorrhage were observed during the first period; however, all of the complications were successfully managed endoscopically. The presence of fibrosis was identified as a significant independent predictor of a prolonged operation time during the first period (coefficient, 5.90; 95 %CI, 2.36 – 9.44, P = 0.002). Conclusions: Our trainees achieved high rates of self-completion and R0 resection without severe complications even during the first 20 cases, suggesting that our training programs using ex vivo animal models are useful for trainees without gastric ESD experience. Study registration: UMIN000013566

Esophageal endoscopic submucosal dissection (ESD) is technically difficult. To make it safer, we developed a novel method using overtube with a traction forceps (OTF) for countertraction during submucosal dissection. We conducted an ex vivo animal study and compared the clinical outcomes between OTF-ESD and conventional method (C-ESD). A total of 32 esophageal ESD procedures were performed by four beginner and expert endoscopists. After circumferential mucosal incision for the target lesion, structured as the isolated pig esophagus 3 cm long, either C-ESD or OTF-ESD was randomly selected for submucosal dissection. All the ESD procedures were completed as en bloc resections, while perforation only occurred in a beginner’s C-ESD procedure. The dissection time for OTF-ESD was significantly shorter than that for C-ESD for both the beginner and expert endoscopists (22.8±8.3 min versus 7.8±4.5 min, P