Clinical Endoscopy

Utility of underwater endoscopic mucosal resection combined with a protruding anchor by saline injection for superficial non-ampullary duodenal tumors: a retrospective study in Japan: Yoshie Nomoto, Satoshi Shinozaki, Yoshimasa Miura, Hiroyuki Osawa, Yuji Ino, Tomonori Yano, Nikolaos Lazaridis, Hironori Yamamoto; Received July 4, 2024 Accepted September 30, 2024 Published online March 12, 2025; DOI: https://doi.org/10.5946/ce.2024.181 [Epub ahead of print]

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/Aims: Underwater endoscopic mucosal resection (UEMR) is the standard resection method for superficial non-ampullary duodenal tumors (SNADETs). We developed a novel UEMR technique that creates an anchor by protruding the distal fold with a saline injection (UEMR-A). The aim of this study was to clarify the usefulness of UEMR-A compared to conventional UEMR (UEMR-C).
Methods
This retrospective observational study included patients who underwent UEMR for SNADETs.
Results
A total of 141 patients were included and divided into UEMR-A (n=54) and UEMR-C (n=87) groups. Lesion resection was performed significantly more frequently by an expert endoscopist in the UEMR-C group compared to the UEMR-A group (p<0.001). The procedure time for UEMR-A was significantly shorter than that for UEMR-C (p=0.018), despite the additional time required for submucosal injection. The R0 resection rate was significantly higher in the UEMR-A group than in the UEMR-C group (p=0.004). The horizontal margins were significantly clearer in the UEMR-A group than in the UEMR-C group (p=0.018). Multivariate analysis revealed that the use of UEMR-A was the only significant positive factor for R0 resection.
Conclusions
The UEMR-A technique for SNADETs appears to improve R0 resection rates and reduce procedure times compared to the UEMR-C technique.

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In-room cytologic evaluation by trained endosonographer for determination of procedure end in endoscopic ultrasound-guided fine needle biopsy of solid pancreatic lesions: a prospective study in Taiwan: Weng-Fai Wong, Yu-Ting Kuo, Wern-Cherng Cheng, Chia-Tung Shun, Ming-Lun Han, Chieh-Chang Chen, Hsiu-Po Wang; Received May 30, 2024 Accepted August 5, 2024 Published online December 12, 2024; DOI: https://doi.org/10.5946/ce.2024.143 [Epub ahead of print]

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub: Background
/Aims: Endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) is an essential tool for tissue acquisition in solid pancreatic tumors. Rapid on-site evaluation (ROSE) by cytologists ensures diagnostic accuracy. However, the universal application of the ROSE is limited by its availability. Therefore, we aimed to investigate the feasibility of determining the end of the procedure based on the results of in-room cytological evaluation by trained endosonographers (IRCETE).
Methods
A training course focusing on the cytological interpretation of common pancreatic tumors was provided to the three endosonographers. After training, the decision to terminate EUS-FNB was made based on IRCETE results. The diagnostic accuracy, concordance rate of diagnostic categories, and sample adequacy were compared with those determined by board-certified cytologists and macroscopic on-site evaluation (MOSE).
Results
We enrolled 65 patients with solid pancreatic tumors, most of whom were malignant (86.2%). The diagnostic accuracy was 90.8% when the end of the procedure was determined based on IRCETE, compared to 87.7% and 98.5% when determined by MOSE and cytologists, respectively (p=0.060). Based on the cytologists’ results, the accuracy of IRCETE in diagnostic category interpretation was 97.3%.
Conclusions
In the absence of ROSE, IRCETE can serve as a supplementary alternative to MOSE in determining the end of tissue sampling with a high accuracy rate.

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The impact of linked color imaging on adenoma detection rate in colonoscopy: a systematic review and meta-analysis: Bruna Haueisen Figueiredo Zwetkoff, Luiz Ronaldo Alberti, Fábio Gontijo Rodrigues, Nelson Carvas Junior, José Celso Ardengh, Otavio Micelli Neto, Fernando Rodrigues Guzman, Marcelo Morganti Ferreira Dias, Guilherme Camarotti de Oliveira Canejo, Carlos Eduardo Oliveira dos Santos; Received March 26, 2024 Accepted May 16, 2024 Published online October 24, 2024; DOI: https://doi.org/10.5946/ce.2024.072 [Epub ahead of print]

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: Colorectal cancer prevention relies on surveillance colonoscopy, with the adenoma detection rate as a key factor in examination quality. Linked color imaging (LCI) enhances lesion contrast and improves the examination performance. This systematic review and meta-analysis aimed to evaluate the effect of LCI on adenoma detection rate in adults who underwent colonoscopy.
Methods
We searched the Medline, PubMed, BIREME, LILACS, and Scientific Electronic Library Online databases for randomized controlled trials comparing the use of LCI versus white light (WL), published up to March 2023. The outcomes included lesion characteristics, number of adenomas per patient, and the additional polyp detection rate.
Results
Sixteen studies were included in the analysis, which showed that LCI was more accurate than WL in detecting adenomas, with an increased number of adenomas detected per patient. Although LCI performed well in terms of lesion size, morphology, and location, the subgroup analyses did not reveal any statistically significant differences between LCI and WL. The addition of LCI did not result in significant improvements in the detection of serrated lesions, and there were no differences in the withdrawal time between groups.
Conclusions
LCI has been shown to be effective in detecting colonic lesions, improving the number of adenomas detected per patient and improving polyp detection rate without negatively affecting other quality criteria in colonoscopy.

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White spots around colorectal tumors are cancer-related findings and may aid endoscopic diagnosis: a prospective study in Japan: Kai Korekawa, Yusuke Shimoyama, Fumiyoshi Fujishima, Hiroshi Nagai, Takeo Naito, Rintaro Moroi, Hisashi Shiga, Yoichi Kakuta, Yoshitaka Kinouchi, Atsushi Masamune; Clin Endosc 2024;57(5):637-646. Published online June 21, 2024; DOI: https://doi.org/10.5946/ce.2024.027

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: During endoscopy, white spots (WS) are sometimes observed around benign or malignant colorectal tumors; however, few reports have investigated WS, and their significance remains unknown. Therefore, we investigated the significance of WS from clinical and pathological viewpoints and evaluated its usefulness in endoscopic diagnosis.
Methods
Clinical data of patients with lesions diagnosed as epithelial tumors from January 1, 2019, to December 31, 2020, were analyzed (n=3,869). We also performed a clinicopathological analysis of adenomas or carcinomas treated with endoscopic resection (n=759). Subsequently, detailed pathological observations of the WS were performed.
Results
The positivity rates for WS were 9.3% (3,869 lesions including advanced cancer and non-adenoma/carcinoma) and 25% (759 lesions limited to adenoma and early carcinoma). Analysis of 759 lesions showed that the WS-positive lesion group had a higher proportion of cancer cases and larger tumor diameters than the WS-negative group. Multiple logistic analysis revealed the following three statistically significant risk factors for carcinogenesis: positive WS, flat lesions, and tumor diameter ≥5 mm. Pathological analysis revealed that WS were macrophages that phagocytosed fat and mucus and were white primarily because of fat.
Conclusions
WS are cancer-related findings and can become a new criterion for endoscopic resection in the future.

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Efficacy of hemostasis by gastroduodenal covered metal stent placement for hemorrhagic duodenal stenosis due to pancreatobiliary cancer invasion: a retrospective study: Yasunari Sakamoto, Taku Sakamoto, Akihiro Ohba, Mitsuhito Sasaki, Shunsuke Kondo, Chigusa Morizane, Hideki Ueno, Yutaka Saito, Yasuaki Arai, Takuji Okusaka; Clin Endosc 2024;57(5):628-636. Published online June 14, 2024; DOI: https://doi.org/10.5946/ce.2023.155

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Background
/Aims: Advanced pancreatic and biliary tract cancers can invade the duodenum and cause duodenal hemorrhagic stenosis. This study aimed to evaluate the efficacy of covered self-expandable metal stents in the treatment of cancer-related duodenal hemorrhage with stenosis.
Methods
Between January 2014 and December 2016, metal stents were placed in 51 patients with duodenal stenosis. Among these patients, a self-expandable covered metal stent was endoscopically placed in 10 patients with hemorrhagic duodenal stenosis caused by pancreatobiliary cancer progression. We retrospectively analyzed the therapeutic efficacy of the stents by evaluating the technical and clinical success rates based on successful stent placement, degree of oral intake, hemostasis, stent patency, and overall survival.
Results
The technical and clinical success rates were 100%. All 10 patients achieved a gastric outlet obstruction scoring system score of three within two weeks after the procedure and had no recurrence of melena. The median stent patency duration and overall survival after stent placement were 52 days (range, 20–220 days) and 66.5 days (range, 31–220 days), respectively.
Conclusions
Endoscopic placement of a covered metal stent for hemorrhagic duodenal stenosis associated with pancreatic or biliary tract cancer resulted in duodenal hemostasis, recanalization, and improved quality of life.

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Clinical significance of peritoneal lavage cytology in duodenal cancer
Yuya Miura, Katsuhisa Ohgi, Ryo Ashida, Yoshiyasu Kato, Shimpei Otsuka, Hideyuki Dei, Katsuhiko Uesaka, Teiichi Sugiura
Surgery.2025; 181: 109256. CrossRef

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Outcomes of partially covered self-expandable metal stents with different uncovered lengths in endoscopic ultrasound-guided hepaticogastrostomy: a Japanese retrospective study: Takeshi Okamoto, Takashi Sasaki, Tsuyoshi Takeda, Tatsuki Hirai, Takahiro Ishitsuka, Manabu Yamada, Hiroki Nakagawa, Takafumi Mie, Takaaki Furukawa, Akiyoshi Kasuga, Masato Ozaka, Naoki Sasahira; Clin Endosc 2024;57(4):515-526. Published online May 10, 2024; DOI: https://doi.org/10.5946/ce.2023.142

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Background
/Aims: The optimal length of the uncovered portion of partially covered self-expandable metal stents (PCSEMSs) used in endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) remains unclear. This study investigated the safety and efficacy of PCSEMSs with different uncovered lengths, with a focus on stent migration and time to recurrent biliary obstruction (RBO).
Methods
Outcomes of patients undergoing EUS-HGS using PCSEMSs with 5-mm and 20-mm uncovered portions at our institution from January 2016 to December 2021 were compared.
Results
Sixty-two patients underwent EUS-HGS using PCSEMS (5/20-mm uncovered portions: 32/30). Stent migration occurred only in the 5-mm group. There were no differences in RBO rates (28.1% vs. 40.0%) or median time to RBO (6.8 vs. 7.1 months) between the two groups. Median overall survival (OS) was longer in the 20-mm group (3.1 vs. 4.9 months, p=0.037) due to the higher number of patients that resumed chemotherapy after EUS-HGS (56.7% vs. 28.1%, p=0.029). Good performance status, absence of hepatic metastases, and chemotherapy after EUS-HGS were independent predictors of longer OS.
Conclusions
No migration was observed in patients treated with PCSEMS with 20-mm uncovered portions. Patients treated with PCSEMS with 20-mm uncovered portions performed at least as well as those treated with 5-mm uncovered portions in all material respects.

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Migration of covered expandable metal stents after endoscopic ultrasound-guided hepaticogastrostomy: stent covering versus stent design?
Todd H. Baron
Clinical Endoscopy.2024; 57(4): 471. CrossRef

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Clinical meaning of sarcopenia in patients undergoing endoscopic treatment: Hiroyuki Hisada, Yosuke Tsuji, Hikaru Kuribara, Ryohei Miyata, Kaori Oshio, Satoru Mizutani, Hideki Nakagawa, Rina Cho, Nobuyuki Sakuma, Yuko Miura, Hiroya Mizutani, Daisuke Ohki, Seiichi Yakabi, Yu Takahashi, Yoshiki Sakaguchi, Naomi Kakushima, Nobutake Yamamichi, Mitsuhiro Fujishiro; Clin Endosc 2024;57(4):446-453. Published online March 22, 2024; DOI: https://doi.org/10.5946/ce.2023.193

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