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Purpose The study aimed to compare the diagnostic performance of washout-parametric imaging (WOPI) with that of conventional contrast-enhanced ultrasound (cCEUS) in differentiating focal liver lesions (FLLs). Methods A total of 181 FLLs were imaged with contrast-enhanced ultrasound using Sonazoid, and the recordings were captured for 10 minutes in a prospective setting. WOPI was constructed from three images, depicting the arterial phase (peak enhancement), the early portal venous phase (1-minute post-injection), and the vasculo-Kupffer phase (5 or 10 minutes post-injection). The intensity variations in these images were color-coded and superimposed to produce a single image representing the washout timing across the lesions. From the 181 FLLs, 30 hepatocellular carcinomas (HCCs), 30 non-HCC malignancies, and 30 benign lesions were randomly selected for an observer study. Both techniques (cCEUS and WOPI) were evaluated by four off-site readers. They classified each lesion as benign or malignant using a continuous rating scale, with the endpoints representing "definitely benign" and "definitely malignant." The diagnostic performance of cCEUS and WOPI was compared using the area under the receiver operating characteristic curve (AUC) with the DeLong test. Interobserver agreement was assessed using the intraclass correlation coefficient (ICC). Results The difference in average AUC values between WOPI and cCEUS was 0.0062 (95% confidence interval, -0.0161 to 0.0285), indicating no significant difference between techniques. The interobserver agreement was higher for WOPI (ICC, 0.77) than cCEUS (ICC, 0.67). Conclusion The diagnostic performance of WOPI is comparable to that of cCEUS in differentiating FLLs, with superior interobserver agreement.

Abstract Helicobacter pylori eradication therapy reduces the risk of gastric cancer. However, it is unclear whether the severity of risk factors for gastric cancer such as atrophy and intestinal metaplasia are reduced after eradication in the long term. We aimed to study long-term changes in endoscopic risk factors for gastric cancer up to 20 years post-eradication. The endoscopic severity of gastritis according to the Kyoto Classification of Gastritis in 167 patients was retrospectively evaluated over an average follow-up 15.7 years. A significant improvement in mean total gastric cancer risk score (4.36 ± 1.66 to 2.69 ± 1.07, p

The first Asia-Pacific consensus recommendations for endoscopic and interventional management of hilar cholangiocarcinoma were published in 2013. Since then, new evidence on the role of endoscopy for management of malignant hilar biliary obstruction (MHBO) has emerged. To update the recommendation, we reviewed the literature using a PICO (population/intervention/comparison/outcomes) framework and created consensus statements. The expert panel voted anonymously using the modified Delphi method and all final statements were evaluated for the quality of evidence and strength of recommendation. The important points with inadequate supporting evidence were classified as key concepts. There were seven statements and five key concepts that reached consensus. The statements and key concepts dealt with multiple aspects of endoscopy-based management in MHBO starting from diagnosis, strategies and options for biliary drainage, management of recurrent biliary obstruction, management of cholecystitis after biliary stenting, and adjunctive treatment before stenting. Although the recommendations may assist physicians in planning the treatment for MHBO patients, they should not replace the decision of a multidisciplinary team in the management of individual patients.

Abstract Objectives This study aimed to prevent the infection risk of environmental contamination by feces during endoscopic procedures. We evaluated the effect of coronavirus disease 2019 (COVID‐19) on the gastrointestinal tract using fecal polymerase chain reaction (PCR) and examined risk factors affecting endoscopic procedures, to develop infection prevention strategies. Methods This single‐center prospective observational study enrolled 32 patients diagnosed with COVID‐19 at Tokyo Medical University Hospital between January and December 2022. We performed reverse transcriptase‐PCR to detect severe acute respiratory syndrome coronavirus 2 in human stool specimens and evaluated the COVID‐19 positivity rate in stool, the effect of vaccination on infection detection, and differences in positivity rates considering different patient backgrounds. Results Among the 32 nasal PCR‐positive patients who underwent fecal PCR testing, the fecal PCR positivity rate was 21.8%. Compared to the negative cases, 71.4% vs. 32% were older than 65 years (p < 0.016), 71.4% vs. 0.8% (p < 0.001) had malignant tumors, the rate during BA.5 variant outbreaks was significantly higher (100% vs. 60% [p = 0.044]), and the rate of diarrheal symptoms was also higher (42.9% vs. 24%). The median collection period for fecal PCR‐positive cases was 2 days after sampling. Conclusions The severe acute respiratory syndrome coronavirus 2 affects not only the upper respiratory tract but also the gastrointestinal tract. These findings may indicate the risk of digestive fluid infection in older patients with gastrointestinal symptoms and immunocompromised patients with malignant tumor comorbidities, especially during the early stages of viral infection. Therefore, it is advisable to establish a system to prevent infection by using personal protective equipment, including eye guards, in future endoscopic procedures.

Abstract Objectives Endoscopic transpapillary gallbladder drainage (ETGBD) is a highly technical procedure, but few studies have evaluated factors that predict its technical success. Therefore, in this study, we sought to identify predictors of technically successful ETGBD. Methods One hundred and eighty‐two patients who underwent ETGBD for acute cholecystitis at our hospital were retrospectively investigated. Factors associated with technical failure were identified by focusing on clinical characteristics, anatomical features (direction of the cystic duct branch and course of the cystic duct), and procedural factors (cystic duct and gallbladder with or without contrast and cystic duct injury). Results The technical success rate was 84.6% (154/182) and the clinical success rate was 96.1% (148/154). The adverse event rate was 11.0% (20/182; cystic duct injury in 13 patients, pancreatitis in six, and liver abscess in one. Univariate and multivariate analyses identified the right cranial direction and spiral‐type course of the cystic duct to be significant anatomical features and cystic duct injury to be a significant procedural feature contributing to the technical failure of ETGBD. Conclusions ETGBD is a highly practical procedure for patients with acute cholecystitis. However, difficulty is encountered in some cases because of anatomical and procedural factors. Our results suggest that ETGBD may be difficult and thus should not be performed in cases with the right cranial direction or spiral‐type course of the cystic duct or those with cystic duct injury.

Abstract Objective Few reports have explored the application of urinary trypsinogen‐2 measurement in the early diagnosis of post‐endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, and none have demonstrated the benefits of noninvasive testing. This study aimed to evaluate the clinical application of the rapid urinary trypsinogen‐2 dipstick test (Nipro, Japan) compared with serum amylase and lipase levels for the early diagnosis of post‐ERCP pancreatitis (PEP). Methods A total of 100 consecutive patients (54 men and 46 women) who were admitted and underwent ERCP at Tokyo Medical University Hospital from August 2021 to December 2021 were recruited. All patients underwent rapid urinary trypsinogen‐2 measurement using the dipstick test before and after ERCP. Measurements were taken 24 h before ERCP for pre‐ERCP and 1–4 h after ERCP for post‐ERCP. Additionally, serum amylase and lipase levels were measured at 8:00 a.m. of the day after ERCP (at least 8 h after ERCP), and their diagnostic abilities for PEP were compared and evaluated. Results PEP occurred in 5/100 patients (5%). The sensitivity, specificity, positive predictive value, and negative predictive value of the dipstick test for diagnosing PEP were 100%, 83.2%, 23.8%, and 100%, respectively. These results were comparable to the diagnostic performance of serum amylase and lipase levels at 8:00 a.m. on the day after ERCP (at least 8 h after ERCP). However, false positives must be considered. Conclusion The dipstick test may be useful in clinical practice as a noninvasive screening test for the early prediction of PEP.

Background/Aims Hybrid endoscopic submucosal dissection (ESD), in which an incision is made around a lesion and snaring is performed after submucosal dissection, has some advantages in colorectal surgery, including shorter procedure time and preventing perforation. However, its value for rescue resection in difficult colorectal ESD cases remains unclear. This study evaluated the utility of rescue hybrid ESD (RH-ESD). Methods We divided 364 colorectal ESD procedures into the conventional ESD group (C-ESD, n=260), scheduled hybrid ESD group (SH-ESD, n=69), and RH-ESD group (n=35) and compared their clinical outcomes. Results Resection time was significantly shorter in the following order: RH-ESD (149 [90–197] minutes) >C-ESD (90 [60–140] minutes) >SH-ESD (52 [29–80] minutes). The en bloc resection rate increased significantly in the following order: RH-ESD (48.6%), SH-ESD (78.3%), and C-ESD (97.7%). An analysis of factors related to piecemeal resection of RH-ESD revealed that the submucosal dissection rate was significantly lower in the piecemeal resection group (25% [20%–30%]) than in the en bloc resection group (40% [20%–60%]). Conclusions RH-ESD was ineffective in terms of curative resection because of the low en bloc resection rate, but was useful for avoiding surgery.

This review outlines several modified versions of the contrast-enhanced ultrasonography Liver Imaging Reporting and Data System (CEUS LI-RADS) that utilize Sonazoid. Furthermore, it discusses the advantages and challenges of diagnosing hepatocellular carcinoma using these guidelines, as well as the authors’ expectations and opinions regarding the next CEUS LI-RADS version. It is possible that Sonazoid could be incorporated into the next version of CEUS LI-RADS.

Abstract We evaluated whether texture and color enhancement imaging (TXI) using a high-definition ultrathin transnasal endoscope (UTE) improves the visibility of early gastric cancer (EGC) compared with white-light imaging (WLI). This study included 31 EGCs observed by TXI mode 2 using a high-definition UTE prior to endoscopic submucosal dissection. The first outcome was to compare the color differences based on Commission Internationale de l’Eclairage L*a*b* color space between EGCs and the surrounding mucosa by WLI and TXI using the UTE (objective appearance of EGC). The second outcome was to assess the visibility of EGCs by WLI and TXI using the UTE in an image evaluation test performed on 10 endoscopists (subjective appearance of EGC). Color differences between EGCs and non-neoplastic mucosa were significantly higher in TXI than in WLI in all EGCs (TXI: 16.0 ± 10.1 vs. WLI: 10.2 ± 5.5 [mean ± standard deviation], P

White light imaging (WLI) is the most common endoscopic technique used for screening of gastrointestinal diseases. However, despite the advent of a new processor that offers sufficient clear illumination and other advanced developments in endoscopic instrumentation, WLI alone is inadequate for detecting all gastrointestinal diseases with abnormalities in mucosal discoloration and morphological changes to the mucosal surface. The recent development of image-enhanced endoscopy (IEE) has dramatically improved the detection of gastrointestinal diseases. Texture and colour enhancement imaging (TXI) is a new type of IEE that enhances brightness, surface irregularities, such as elevations or depressions, and subtle colour changes. TXI with two modes, namely modes 1 and 2, can selectively enhance brightness in dark areas of an endoscopic image and subtle tissue differences such as slight morphological or colour changes while simultaneously preventing over-enhancement. Several clinical studies have investigated the efficacy of TXI for detecting and visualizing gastrointestinal diseases, including oesophageal squamous cell carcinoma (ESCC), Barret’s epithelium, gastric cancer, gastric mucosal atrophy and intestinal metaplasia. Although TXI is often more useful for detecting and visualizing gastrointestinal diseases than WLI, it remains unclear whether TXI outperforms other IEEs, such as narrow-band imaging (NBI), in similar functions, and whether the performance of TXI modes 1 and 2 are comparable. Therefore, large-scale prospective studies are needed to compare the efficacy of TXI to WLI and other IEEs for endoscopic evaluation of patients undergoing screening endoscopy. Here, we review the characteristics and efficacy of TXI for the detection and visualization of gastrointestinal diseases.Key MessagesTXI mode 1 can improve the visibility of gastrointestinal diseases and qualitative diagnosis, especially for diseases associated with colour changes.The enhancement of texture and brightness with TXI mode 2 enables the detection of diseases, and is ideal for use in the first screening of gastrointestinal tract.

Background A new image-enhanced endoscopy method called texture and colour enhancement imaging (TXI) enhances brightness, surface irregularities, and subtle colour changes in endoscopic images. However, it is unclear whether TXI and narrow-band imaging (NBI) with third-generation high-vision transnasal ultrathin endoscopy are advantageous over white-light imaging (WLI) for detecting atrophy, intestinal metaplasia, map-like redness and gastric cancer. We investigated to compare the endoscopic efficacy for evaluation of gastritis between TXI and NBI with high-vision transnasal endoscopy and clarified the endoscopic efficacy of TXI and NBI compared to WLI.Methods We enrolled 60 patients who underwent high-vision transnasal endoscopy as part of a health check-up from March to November 2021 and randomized patients into two groups (the WLI-NBI group and the WLI-TXI group) using the minimization method based on Helicobacter pylori infection status, age and sex. Colour differences determined using the International Commission on Illumination 1976 (L∗, a∗, b∗) colour space was compared between WLI and TXI or NBI.Results No significant differences were observed in colour differences surrounding atrophy, intestinal metaplasia and map-like redness between NBI and TXI (p = .553, .057 and .703, respectively). Endoscopic scores based on the Kyoto classification of gastritis for atrophy, intestinal metaplasia, and map-like redness were similar between WLI and TXI. In contrast, NBI identified intestinal metaplasia at a significantly greater rate than WLI (p = .018). Further, colour differences surrounding atrophy and intestinal metaplasia on TXI and NBI were significantly greater than those on WLI (atrophy: TXI vs WLI p = .003, NBI vs WLI p

Here, Nishijima et al. perform a large-scale analysis of the human gut virome in the Japanese 4D cohort of 4198 deeply phenotyped individuals, revealing thousands of bacteriophage genomes, virus-bacteria interactions, and describing associations with various host and environmental factors.

Abstract Backgrounds The pharynx has no muscularis mucosae, so it is unclear whether diagnostic techniques used for the esophagus can be applied to the pharynx. This study investigated the usefulness of magnifying endoscopy with narrowband imaging using the Japan Esophageal Society (JES) classification for predicting the depth of invasion and lymph node metastasis (LNM) in pharyngeal cancer. Methods A total of 123 superficial pharyngeal carcinoma lesions that had been observed preoperatively with magnifying endoscopy with narrowband imaging between January 2014 and June 2021 were analyzed. Predictors of subepithelial invasion (SEP) and LNM were sought based on endoscopic findings, including microvascular morphology, using the JES classification. Results The lesions were divided into carcinoma in situ (n = 41) and SEP (n = 82). Multivariate analysis identified B2–B3 vessels (odds ratio [OR] 6.54, 95% confidence interval [CI] 1.74–24.61, p = 0.005) and a middle/large avascular area (OR 4.15, 95% CI 1.18–14.62, p = 0.027) as independent predictors of SEP. Significant predictors of LNM were protruding type, B2–B3 vessels, middle/large avascular area, SEP, venous invasion, lymphatic invasion, and tumor thickness > 1000 μm. Median tumor thickness increased significantly in the order of B1

Abstract A 61‐year‐old Helicobacter pylori‐positive female with gastroesophageal reflux disease has undergone surveillance endoscopy every year for 13 years at Tokyo Medical University Hospital. At the first surveillance in 2009, conventional white light endoscopy showed a 10‐mm whitish slightly depressed lesion at the lesser curvature of the gastric cardia. This lesion gradually increased in size to 15 mm over the 13‐year observational period. Indigo carmine chromoendoscopy, narrow band imaging, and texture and color enhancement imaging in both mode 1 and mode 2 clearly emphasized the presence of a depressed whitish mucosa around the gastric mucosa compared with white light imaging. None of the three image‐enhanced endoscopy techniques showed any abnormality in the vascular or structural pattern. Pathological findings showed squamous epithelium without atypia and revealed no evidence of malignancy in the stomach. We thus report a case of gastric squamous metaplasia without gastric neoplastic lesion in the gastric cardia whose lesions were endoscopically observed to change the size for more than 10 years and whose lesions were endoscopically evaluated with a texture and color enhancement imaging mode 1 and mode 2 and narrow band imaging.

BackgroundInflammatory bowel disease (IBD) is a chronic intestinal disorder characterized by recurrent flare-ups and remission. Leucine-rich α2-glycoprotein (LRG) has been developed as a new serum biomarker of disease activity in patients with IBD. However, there have been no reports on whether plasma LRG can be used as an alternative to serum LRG. Therefore, in this retrospective study, we evaluated the usefulness of plasma LRG compared to serum LRG.MethodsWe conducted a single-center retrospective observational study. A total of 108 IBD patients (ulcerative colitis [UC], 56; Crohn's disease [CD], 52) who received treatment at Sapporo Medical University Hospital between August 2020 and September 2021 were enrolled. Serum and plasma LRG levels were measured using the NANOPIA LRG kit. Disease activity was assessed using the Crohn's Disease Activity Index (CDAI) for CD and partial Mayo (pMayo) score for UC. Endoscopic activity was evaluated using the Mayo Endoscopic Subscore (MES) and Ulcerative Colitis Endoscopic Index of Severity (UCEIS) in patients with UC and the Simple Endoscopic Score for Crohn's Disease (SES-CD) score in patients with CD.ResultsSerum LRG levels significantly correlated with plasma LRG levels (r = 0.990, pConclusionThe present study showed that plasma LRG levels correlate well with serum LRG levels. Therefore, plasma LRG can be clinically applied as a biomarker for assessing endoscopic disease activity in patients with IBD.

Summary: Background: The impact of stroma-targeting therapy on tumor immune suppression is largely unexplored. An RNA oligonucleotide, STNM01, has been shown to repress carbohydrate sulfotransferase 15 (CHST15) responsible for tumor proteoglycan synthesis and matrix remodeling. This phase I/IIa study aimed to evaluate the safety and efficacy of STNM01 in patients with unresectable pancreatic ductal adenocarcinoma (PDAC). Methods: This was an open-label, dose-escalation study of STNM01 as second-line therapy in gemcitabine plus nab-paclitaxel-refractory PDAC. A cycle comprised three 2-weekly endoscopic ultrasound-guided locoregional injections of STNM01 at doses of 250, 1,000, 2,500, or 10,000 nM in combination with S-1 (80–120 mg twice a day for 14 days every 3 weeks). The primary outcome was the incidence of dose-liming toxicity (DLT). The secondary outcomes included overall survival (OS), tumor response, changes in tumor microenvironment on immunohistopathology, and safety (jRCT2031190055). Findings: A total of 22 patients were enrolled, and 3 cycles were repeated at maximum; no DLT was observed. The median OS was 7.8 months. The disease control rate was 77.3%; 1 patient showed complete disappearance of visible lesions in the pancreas and tumor-draining lymph nodes. Higher tumoral CHST15 expression was associated with poor CD3+ and CD8+ T cell infiltration at baseline. STNM01 led to a significant reduction in CHST15, and increased tumor-infiltrating CD3+ and CD8+ T cells in combination with S-1 at the end of cycle 1. Higher fold increase in CD3+ T cells correlated with longer OS. There were 8 grade 3 adverse events. Interpretation: Locoregional injection of STNM01 was well tolerated in patients with unresectable PDAC as combined second-line therapy. It prolonged survival by enhancing T cell infiltration in tumor microenvironment. Funding: The present study was supported by the Japan Agency for Medical Research and Development (AMED).

High-intensity focused ultrasound (HIFU) is a novel advanced therapy for unresectable pancreatic cancer (PC). HIFU therapy with chemotherapy is being promoted as a novel method to control local advancement by tumor ablation. We evaluated the therapeutic effects of HIFU therapy in locally advanced and metastatic PC. PC patients were treated with HIFU as an optional local therapy and systemic chemotherapy. The FEP-BY02 (Yuande Bio-Medical Engineering) HIFU device was used under ultrasound guidance. Of 176 PC patients, 89 cases were Stage III and 87 were Stage IV. The rate of complete tumor ablation was 90.3%, while that of symptom relief was 66.7%. The effectiveness on the primary lesions were as follows: complete response (CR): n = 0, partial response (PR): n = 21, stable disease (SD): n = 106, and progressive disease (PD): n = 49; the primary disease control rate was 72.2%. Eight patients underwent surgery. The median survival time (MST) after diagnosis for HIFU with chemotherapy compared to chemotherapy alone (100 patients in our hospital) was 648 vs. 288 days (p < 0.001). Compared with chemotherapy alone, the combination of HIFU therapy and chemotherapy demonstrated significant prolongation of prognosis. This study suggests that HIFU therapy has the potential to be a novel combination therapy for unresectable PC.

Abstract Background Coronavirus disease 2019 (COVID-19) has a broad spectrum from respiratory and nasopharyngeal symptoms, cerebrovascular diseases, impaired consciousness, and skeletal muscle injury. Emerging evidence has indicated the neural spread of this novel coronavirus. Restless legs syndrome (RLS) is a common neurological, sensorimotor disorder, but highly under diagnosis disorder. Restless anal syndrome as restless legs syndrome variant associated with COVID-19 has been previously not published. We report a case presenting with restless anal syndrome following COVID-19. Case presentation Although a 77-year-old male with COVID-19 improved to normal respiratory function 21 days after admission and treatment of favipiravir 200 mg per day for 14 days and dexamethasone 6.6 mg per day for 5 days, the insomnia and anxiety symptoms remained. Several weeks after discharge, he gradually began to experience restless, deep anal discomfort, approximately 10 cm from the perineal region. The following features were observed in the anal region; urge to move is essential, with worsening with rest, improvement with exercise, and worsening at evening. Colonoscopy revealed internal haemorrhoids without other rectal lesions. Neurological findings including deep tendon reflex, perineum loss of sensory and spinal cord injury, revealed no abnormalities. Diabetes militias, kidney dysfunction and iron deficiency status were not confirmed. Family history of RLS and periodic limb movements were not observed. Clonazepam at 1.5 mg per day resulted in the alleviation restless anal discomfort. Conclusions We reported a case presenting with restless anal syndrome following affection of COVID-19 as restless legs syndrome variant. This case fulfilled 4 essential features of RLS, urge to move, worsening with rest, improvement with exercise, and worsening at evening. To date, no case of restless anal syndrome associated with COVID-19 has been previously published. This case report may reflect the associative impacts of COVID-19 on the neuropsychiatric state. The long-term outcomes of neuropsychiatric conditions should continue to be monitored.

Abstract Pancreatic duct stenting is a well-established method for reducing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. However, there is no consensus on the optimal type of plastic stent. This study aimed to evaluate the feasibility and safety of a new 4-Fr plastic stent for pancreatic duct stenting. Forty-nine consecutive patients who placed the 4-Fr stent into the pancreatic duct (4Fr group) were compared with 187 consecutive patients who placed a conventional 5-Fr stent (control group). The primary outcome was technical success. Complications rate, including post-ERCP pancreatitis (PEP) were the secondary outcomes. Propensity score matching was introduced to reduce selection bias. The technical success rate was 100% in the 4Fr group and 97.9% in the control group (p = 0.315). Post-ERCP amylase level was significantly lower in the 4-Fr group than the control group before propensity score matching (p = 0.006), though without statistical significance after propensity score matching (p = 0.298). The rate of PEP in the 4Fr group (6.1%) was lower than the control group (15.5%), though without statistical significance before (p = 0.088) and after (p = 1.00) propensity score matching. Pancreatic duct stenting using a novel 4-Fr plastic stent would be at least similar or more feasible and safe compared to the conventional plastic stent.

Mediastinal cavernous hemangioma is a rare lesion requiring diagnosis without invasive procedure due to the risk of hemorrhage, which can be massive and even fatal. Here we describe the successful diagnosis of such a lesion using technetium-99m diethylenetriamine penta-acetic acid human serum albumin (99mTc-HSA-D) scintigraphy. A 36-year-old female with a 3-week back pain underwent endoscopic ultrasonography, contrast-enhanced CT, and MRI dynamic study which together revealed a submucosal tumor of the esophagus; likely to be either hemangioma or lymphangioma. Because of poor or no enhancement, it was impossible to distinguish the nature of the lesion. However, using delayed blood-pool imaging of 99mTc-HSA-D (at 40 minutes postinjection), and the characteristic accumulation, the tumor was clearly identifiable as an esophageal hemangioma. This case shows 99mTc-HSA-D scintigraphy to be an effective noninvasive imaging method to capture the characteristic hemodynamics of hemangioma.

Here, we report the case of a 30-year-old female patient who underwent coil embolization for unruptured splenic artery aneurysm without any complication at 26 weeks of pregnancy with reduction in fetal radiation exposure. The patient did not suffer from rupture of splenic artery aneurysm during or after procedure. Pregnancy is a risk factor of splenic artery aneurysm rupture with a high mortality rate. Transcatheter arterial embolization at 26 weeks of pregnancy might be a better treatment alternative for a pregnant patient with splenic artery aneurysm with respect to the endurance of fetal radiation exposure to prevent aneurysm rupture.

Abstract This study aimed to determine the clinicopathological features of the subtypes of ampullary carcinoma (AC) to explore the indications for endoscopic papillectomy (EP) in early AC. Fifty-seven patients with AC who underwent curative resection were retrospectively reviewed. The 0/IA stages were significantly more common in the intestinal type (I-type) than in the mixed and pancreatobiliary type (M&PB-type) (90.7% vs 35.7%, P

Abstract We report the case of a patient with a giant Brunner's gland hamartoma that was pathologically diagnosed by endoscopic mucosal resection. A 69‐year‐old woman presented with intermittent abdominal pain, and imaging revealed a smooth saccular submucosal tumor, 40 mm in diameter, on the anterior wall of the duodenal bulb. Brunner's gland and smooth muscle tissue were observed on endoscopic ultrasound‐guided fine‐needle aspiration biopsy, which resulted in the preoperative diagnosis of a duplication cyst. However, subsequent endoscopic mucosal resection established a final histopathological diagnosis of Brunner's gland hamartoma.

Gastric outlet obstruction (GOO) can be caused by benign and malignant diseases. GOO often leads to a decreased quality of life, because of nausea, vomiting, and problems with oral food intake. Traditionally, surgical gastrojejunostomy (SGJ) has been the primary treatment for GOO. Endoscopic enteral stenting (EES) has also been carried out for the treatment of malignant GOO. In recent years, endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) using a lumen apposing metal stent has emerged as a procedure to treat patients with GOO, as an alternative to surgery or to standard endoscopy when EES is not possible. Various techniques, such as direct EUS-GE, assisted EUS-GE, and EUS-guided balloon-occluded gastrojejunostomy bypass have been established to perform EUS-GE safety and accurately. Previous reports of EUS-GE with lumen apposing metal stent demonstrated that the technical and clinical success rates were 87% to 100% and 84% to 100%, respectively, without differentiating the various procedural techniques. The adverse events rate ranged from 0% to 18.1%, and included stent misdeployment, bleeding, peritonitis, leakage, abdominal pain, etc. In addition, the reintervention rate ranged from 0% to 15.1%. Moreover, a comparison of EUS-GE and SGJ showed that there was no significant difference in clinical success, rate of adverse events, or need for reintervention between these procedures. On the other hand, studies comparing EUS-GE with EES showed that EUS-GE may have higher clinical success and a lower rate of stent failure requiring repeated intervention than EES. Furthermore, EUS-GE has been used in several clinical scenarios, such as the management of endoscopic retrograde cholangiopancreatography in patients who underwent Roux-en-Y gastric bypass, or for the treatment of afferent loop syndrome. The present review describes the presently available EUS-GE techniques and introduces the recent clinical advances in the treatment of GOO.

Gastric outlet obstruction (GOO) can be caused by periampullary malignancies and often leads to a reduction in a patient’s quality of life. Recently, endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) using a lumen-apposing self-expandable metal stent (LAMS) has been developed as a minimally invasive and durable endoscopic treatment for GOO. There are three types of EUS-GE technique: (1) the direct technique; (2) device-assisted techniques, such as a balloon catheter, nasobiliary drainage tube, and ultraslim endoscopy; and (3) EUS-guided double balloon-occluded gastrojejunostomy bypass. Previous reports of EUS-GE with LAMS have shown technical and clinical success rates (regardless of technique and etiology) of 87%–100% and 84%–100%, respectively. Studies comparing EUS-GE and surgical gastrojejunostomy have shown similar success rates, reintervention rates, and cost benefits, with a lower rate of early adverse events in EUS-GE. A comparison of EUS-GE and endoscopic enteral stent placement revealed similar technical success rates, but initial clinical success rate was higher and the rate of stent failure requiring reintervention was lower with EUS-GE.

Irreversible electroporation (IRE) is a novel form of soft tissue ablation therapy that uses high-current electrical pulses to induce the formation of pores in the cell membrane, leading to cell death. Although outcome data for the ablation of hepatocellular carcinoma (HCC) by IRE are limited, early results are encouraging and may suggest equivalency to the outcomes achieved by thermal ablation methods such as radiofrequency ablation (RFA) and microwave ablation (MWA). However, IRE can be a challenging and very time-consuming procedure compared to RFA and MWA. In this review article, we not only evaluate the efficacy and safety of IRE for the treatment of HCC, but also discuss imaging guidance, ablation monitoring, and endpoint assessment, with a particular focus on ultrasonography.

Shear wave (SW) dispersion imaging is a newly developed imaging technology for assessing the dispersion slope of SWs, which is related to tissue viscosity in diffuse liver disease. Our preclinical and preliminary clinical studies have shown that SW speed is more useful than dispersion slope for predicting the degree of fibrosis and that dispersion slope is more useful than SW speed for predicting the degree of necroinflammation. Thus, dispersion slope, which reflects viscosity, may provide additional pathophysiological insight into diffuse liver disease.

This paper presents the first version of clinical practice guidelines for intrahepatic cholangiocarcinoma (ICC) established by the Liver Cancer Study Group of Japan. These guidelines consist of 1 treatment algorithm, 5 background statements, 16 clinical questions, and 1 clinical topic, including etiology, staging, pathology, diagnosis, and treatments. Globally, high incidence of ICC has been reported in East and Southeast Asian countries and the incidence has been gradually increasing in Japan and also in Western countries. Reported risk factors for ICC include cirrhosis, hepatitis B/C, alcohol consumption, diabetes, obesity, smoking, nonalcoholic steatohepatitis, and liver fluke infestation, as well as biliary diseases, such as primary sclerosing cholangitis, hepatolithiasis, congenital cholangiectasis, and Caroli disease. Chemical risk factors include thorium-232, 1,2-dichloropropane, and dichloromethane. CA19-9 and CEA are recommended as tumor markers for early detection and diagnostic of ICC. Abdominal ultrasonography (US), CT, and MRI are effective imaging modalities for diagnosing ICC. If bile duct invasion is suspected, imaging modalities for examining the bile ducts may be useful. In unresectable cases, tumor biopsy should be considered when deemed necessary for the differential diagnosis and drug therapy selection. The mainstay of treatment for patients with Child-Pugh class A or B liver function is surgical resection and drug therapy. If the patient has no regional lymph node metastasis and has a single tumor, resection is the treatment of choice. If both regional lymph node metastasis and multiple tumors are present, drug therapy is the first treatment of choice. If the patient has either regional lymph node metastasis or multiple tumors, resection or drug therapy is selected depending on the extent of metastasis or the number of tumors. If distant metastasis is present, drug therapy is the treatment of choice. Percutaneous ablation therapy may be considered for patients who are ineligible for surgical resection or drug therapy due to decreased hepatic functional reserve or comorbidities. For unresectable ICC without extrahepatic metastasis, stereotactic radiotherapy (tumor size ≤5 cm) or particle radiotherapy (no size restriction) may be considered. ICC is generally not indicated for liver transplantation, and palliative care is recommended for patients with Child-Pugh class C liver function.

Background and study aims Feasibility of EUS-guided choledochoduodenostomy (EUS-CDS) using available lumen-apposing stents (LAMS) is limited by the size of the common bile duct (CBD) (≤ 12 mm, cut-off for experts; 15 mm, cut-off for non-experts). We aimed to assess the prevalence and predictive factors associated with CBD size ≥ 12 and 15 mm in naïve patients with malignant distal biliary obstruction (MDBO). Patients and methods This was a prospective cohort study involving 22 centers with assessment of CBD diameter and subjective feasibility of the EUS-CDS performance in naïve jaundiced patients undergoing EUS evaluation for MDBO. Results A total of 491 patients (mean age 69 ± 12 years) with mean serum bilirubin of 12.7 ± 6.6 mg/dL entered the final analysis. Dilation of the CBD ≥ 12 and 15 mm was detected in 78.8 % and 51.9 % of cases, respectively. Subjective feasibility of EUS-CDS was expressed by endosonographers in 91.2 % for a CBD ≥ 12 mm and in 96.5 % for a CBD ≥ 15 mm. On multivariate analysis, age (P

Abstract A 15‐year‐old boy was referred to our hospital with elevated hepatobiliary enzyme levels and jaundice. Magnetic resonance cholangiopancreatography performed at the previous medical facility revealed a stricture of the intrahepatic and extrahepatic bile duct. Computed tomography showed dilatation and wall thickness of the intrahepatic bile ducts. Primary sclerosing cholangitis or cholangiocarcinoma was suspected. Endoscopic retrograde cholangiopancreatography (ERCP) showed stricture in the intrahepatic and extrahepatic bile duct. On admission, the eosinophil count in the peripheral blood was normal; however, rapid hypereosinophilia in the peripheral blood was observed after admission, leading us to suspect eosinophilic cholangitis (EC). A bile duct biopsy showed inflammatory cells and eosinophil infiltration during a second ERCP. The patient was diagnosed with EC based on histopathology.

It remains unclear whether texture- and color-enhancement imaging (TXI) and narrow-band imaging (NBI) provide an advantage over white-light imaging (WLI) in Barrett’s esophagus. We compared endoscopic findings and color differences between WLI and image-enhanced endoscopy (IEE) using a third-generation ultrathin endoscope. We retrospectively enrolled 40 patients who evaluated Barrett’s esophagus using WLI, TXI, and NBI. Color differences determined using the International Commission on Illumination 1976 (L∗, a∗, b∗) color space among Barrett’s epithelium, esophageal, and gastric mucosa were compared among the endoscopic findings. As the secondary outcome, we assessed the subjective visibility score among three kinds of endoscopic findings. The prevalence of Barrett’s esophagus and gastroesophageal reflux disease (GERD) in WLI was 82.5% and 47.5%, respectively, and similar among WLI, TXI, and NBI. Color differences between Barrett’s epithelium and esophageal or gastric mucosa on NBI were significantly greater than on WLI (all p < 0.05). However, the color difference between Barrett’s epithelium and esophageal mucosa was significantly greater on NBI than TXI (p < 0.001), and the visibility score of Barrett’s epithelium detection was significantly greater on TXI than NBI (p = 0.022), and WLI (p = 0.016). High-vision, third-generation ultrathin endoscopy using NBI and TXI is useful for evaluating Barrett’s epithelium and GERD compared with WLI alone.

Background: The use of an endoscopic position detection unit (UPD) enables better and more objective understanding of the shape and position of the colonoscope. Here, we investigated the reproducibility of the insertion of a colonoscope with UPD. Materials and Methods: Study participants were 122 patients who received a colonoscopy with UPD twice for the purpose of large bowel screening and surveillance. The mean age of participants was 69.7 ± 10.4 years, and the male-to-female ratio was 9.2:1. The colonoscope insertion technique was primarily based on the shaft-holding, shortening insertion method. The cecal intubation time was recorded; the method used for passing through the sigmoid/descending colon junction (SDJ) and the hepatic flexure. Results: The mean cecal intubation time was 990 ± 511 s. The cecal intubation time and the patterns for passing through the SDJ and hepatic flexure were significantly correlated between the first and second colonoscopies. Conclusion: Use of a UPD revealed good reproducibility of colonoscope insertion. This is the first time we have proved that both time and pattern are inserted in much the same way for the first and second times. In patients’ conducted UPD combination TCS after the second time, it was suggested that individual tailor-made insertions are possible based on the information from the first time.

Abstract Various efforts to improve technical success rates and decrease adverse event rates have also been described in endoscopic ultrasound (EUS)‐guided choledochoduodenostomy (CDS). In particular, lumen‐apposing metal stents (LAMS) may open novel opportunities in EUS‐biliary drainage (BD). To date, various studies have been reported with EUS‐CDS using LAMS, so we should clarify the benefits and limitations of recent EUS‐CDS based on developments in both techniques and devices. In this review, we provide technical tips and describe recent developments in EUS‐CDS, along with a review of the recent literature (between 2015 and 2020). The overall technical success rate is 95.0% (939/988), and the overall clinical success rate is 97.0% (820/845). The most frequent adverse event is cholangitis or cholecystitis (24.5%, 27/110). According to previous review, pneumoperitoneum (28%, 9/34) or peritonitis associated with bile leak (23.5%, 8/34) was most commonly observed. This difference might be based on improvements in dilation devices or the use of covered metal stents. Several randomized controlled trials comparing EUS‐CDS and endoscopic retrograde cholangiopancreatography (ERCP) for malignant biliary obstruction have recently been reported. To summarize, overall technical success rates for ERCP and EUS‐CDS were 92.7% (101/109) and 91.1% (72/79), respectively (p = 0.788). Overall clinical success rates for ERCP and EUS‐CDS were 94.1% (96/102) and 93.6% (72/78), respectively (p = 0.765). Further high‐quality evidence is needed to establish EUS‐CDS as a primary drainage technique.

Objectives Useful indices to determine whether to reduce the dose of 5-aminosalicylic acid (5-ASA) in patients with ulcerative colitis (UC) during remission remain unclear. We aimed to analyze the rate and risk factors of relapse after reducing the dose of oral 5-ASA used for maintenance therapy of UC. Methods UC patients whose 5-ASA dose was reduced in clinical remission (partial Mayo score of ≤ 1) at our institution from 2012 to 2017 were analyzed. Various clinical variables of patients who relapsed after reducing the dose of oral 5-ASA were compared with those of patients who maintained remission. Risk factors for relapse were assessed by univariate and multivariate logistic regression analyses. Cumulative relapse-free survival rates were calculated using the Kaplan–Meier method. Results A total of 70 UC patients were included; 52 (74.3%) patients maintained remission and 18 (25.7%) patients relapsed during the follow-up period. Multivariate analysis indicated that a history of acute severe UC (ASUC) was an independent predictive factor for clinical relapse (p = 0.024, odds ratio: 21, 95% confidence interval: 1.50–293.2). Based on Kaplan–Meier survival analysis, the cumulative relapse-free survival rate within 52 weeks was 22.2% for patients with a history of ASUC, compared with 82.0% for those without. the log-rank test showed a significant difference in a history of ASUC (p < 0.001). Conclusions Dose reduction of 5-ASA should be performed carefully in patients who have a history of ASUC.

Case report: Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) is a minimally invasive technique for biliary system drainage that is used in adult patients with biliary obstruction whose papilla of Vater cannot be accessed. We report a pediatric patient who developed complete obstruction of left hepatic duct associated with liver injury and underwent EUS-HGS as a bridge to the definitive biliary reconstruction. A 7-year-old boy sustained a liver injury (Grade IV) developed bile peritonitis post-traumatic day 17 and underwent perihepatic drainage followed by endoscopic retrograde cholangiopancreatography, which revealed persistent bile leakage from B8. The left biliary system was not visible. A 7-Fr plastic stent was placed into the right biliary system, but 1 week later the patient developed diffuse dilatation of the left biliary system due to complete obstruction of left hepatic duct. EUS-HGS was performed to drain the left biliary system. A dilated bile duct (B2) was accessed using a needle through the EUS probe. A 7-Fr plastic stent was placed into B2 over the guidewire. Eight months later, he underwent elective exploratory laparotomy and hepaticojejunostomy by pediatric hepatobiliary surgeons. Conclusion: Temporarily draining the biliary system by EUS-HGS is a viable option prior to definitive biliary reconstructive surgery.

The aim of this study was to compare the diagnostic performance of Contrast-Enhanced US Liver Imaging Reporting and Data System (CEUS LI-RADS) version 2017, which includes portal- and late-phase washout as a major imaging feature, with that of modified CEUS LI-RADS, which includes Kupffer-phase findings as a major imaging feature. Participants at risk of hepatocellular carcinoma (HCC) with treatment-naïve hepatic lesions (≥1 cm) were recruited and underwent Sonazoid-enhanced US. Arterial phase hyperenhancement (APHE), washout time, and echogenicity in the Kupffer phase were evaluated using both criteria. The diagnostic performance of both criteria was analyzed using the McNemar test. The evaluation was performed on 102 participants with 102 lesions (HCCs (n = 52), non-HCC malignancies (n = 36), and benign (n = 14)). Among 52 HCCs, non-rim APHE was observed in 92.3% (48 of 52). By 5 min, 73.1% (38 of 52) of HCCs showed mild washout, while by 10 min or in the Kupffer phase, 90.4% (47 of 52) of HCCs showed hypoenhancement. The sensitivity (67.3%; 35 of 52; 95% CI: 52.9%, 79.7%) of modified CEUS LI-RADS criteria was higher than that of CEUS LI-RADS criteria (51.9%; 27 of 52; 95% CI: 37.6%, 66.0%) (p = 0.0047). In conclusion, non-rim APHE with hypoenhancement in the Kupffer phase on Sonazoid-enhanced US is a feasible criterion for diagnosing HCC.

Abstract Salivary polyamines are potential non-invasive tools for screening various types of cancers. For clinical use, the reproducibility of these metabolites should be evaluated under various storage conditions, including duration and temperature, to establish standard operating protocols. Polyamines and amino acids in unstimulated whole saliva were quantified via liquid chromatography-mass spectrometry. Concentrations of time course samples were analysed after short-term storage for up to 240 min and long-term storage for up to 8 days under various storage conditions. As expected, storage at the lowest temperature (−18 °C) exerted the least pronounced effects on the quantified values in both tests. At a higher temperature, polyamines were more stable than amino acids, as evident from polyamine profiling. Addition of ethanol significantly stabilized polyamine profiles even at a higher temperature. Comparative processing of saliva revealed a minor effect of the solvent, whereas drying had a more prominent effect on polyamine profiles. Computational analyses evaluated the ability of polyamines to discriminate pancreatic cancer from controls. Repeated noise added tests were designed on the basis of the results of the storage tests; these analyses confirmed that the discriminative abilities were robust. These data contribute to the standardization of salivary storage conditions, thereby highlighting the clinical utility of saliva.

A rare pediatric case of pancreaticobiliary maljunction (PBM) with pancreas divisum is reported. The case showed extremely rare arrangement of the biliary tree and pancreatic duct; the common channel usually seen in PBM did not exist and the common bile duct was connected to the dorsal pancreatic duct via a dilated intermediary duct, in which a large protein plug had formed. The common bile duct was not dilated at all. All of these anomalies may have been caused by abnormal development of the ventral and dorsal pancreatic ducts at an early gestational age.We report a very rare pediatric case of pancreaticobiliary maljunction (PBM) complicated with pancreas divisum. In this case, the common bile duct showed a normal caliber and it was connected to the dorsal pancreatic duct through an intermediary dilated duct, which contained a protein plug that dammed up bile and pancreatic juice flow. This anomaly is very similar to type IIIc3 choledochal cyst, whose classification was addressed by Komi et al. (1), but it differed in the following point; in our case, the common bile duct did not connect to the duodenum through the ampulla of Vater (the common channel was absent) and bile was drained to the duodenum through Santorini duct. These quite rare anomalies might have been caused in the fetus by some kind of maldevelopment of the ventral and dorsal pancreatic ducts. Keywords: Pancreaticobiliary maljunction, Pancreas divisum, Pancreatitis