Late-onset Rupture of the Intrahepatic Pseudoaneurysm Developed by Endoscopic Ultrasonography-guided Hepaticogastrostomy: A Case Report and Literature Review.

Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) has emerged as an alternative drainage technique for patients with malignant biliary obstruction. However, few reports have discussed the occurrence of late-onset rupture of hepatic artery pseudoaneurysms following EUS-HGS. A recently available drill dilator equipped with a long screw segment was used in the dilation step of EUS-HGS. We highlight the potential concern that this long screw segment may increase the risk of damage to the hepatic artery, leading to late-onset life-threatening rupture of a pseudoaneurysm.

Impact of a Time-Related Benchmark on the Adenoma Detection Rate in Surveillance Colonoscopy: A STROBE Statement-Oriented Cross-Sectional Cohort Study.

BACKGROUND/AIMS: Colorectal adenomas are precursor lesions of globally increasing colorectal cancer. Hence, a high adenoma detection rate in colonoscopy is pivotal. We investigated the clinical impact of stratified colonoscopy observation time combined with observation time/intubation time ratio on the detection of colorectal adenomas. MATERIALS AND METHODS: We conducted a single-center retrospective study including 369 consecutive patients who underwent colonoscopy following fecal immunochemical tests between May 2021 and April 2022. The primary outcome measure was the impact of the stratified observation time and observation time/ intubation time ratio (category 1: <6.0 minutes and <1.0, category 2: <6.0 minutes and ≥1.0, category 3: ≥6.0 minutes and <1.0, and category 4: ≥6.0 minutes and ≥1.0) on adenoma detection rate. RESULTS: Cecum intubation was obtained in 367 patients (99.5%). Adenomas were detected in 226 patients (61.2%). From the univariate analysis, age ≥53 years, habitual alcohol intake, colonoscopy attachment (+), and observation time with observation time/intubation time ratio categories 3 and 4 were determined as significant factors for adenoma detection rate. From the logistic regression analysis, age ≥ 53 years (odds ratio: 4.86, 95% CI: 2.25-10.52), habitual alcohol intake (odds ratio: 2.26, 95% CI: 1.33-3.82), category 3 (odds ratio: 3.66, 95% CI: 1.81-7.45), and category 4 (odds ratio: 5.60, 95% CI: 2.92-10.73) were significant factors for adenoma detection rate. CONCLUSION: We propose the observation time with observation time/intubation time ratio combined benchmark (with categories' thresholds based on observation time >6 minutes and scope withdrawal time exceeding intubation time [observation time/intubation time ratio > 1]) as a novel colonoscopy quality indicator. These findings represent an important educational message for endoscopists.

A novel concept of passive loop-forming wire-guided biliary cannulation using an ultra-deep angled tip guidewire (with video).

Background and study aims Wire-guided biliary cannulation (WGBC) is a standard technique during endoscopic retrograde cholangiopancreatography-related interventions. However, no dedicated guidewire is available. We investigated a novel "passive loop-forming WGBC" concept using a 0.035-inch ultra-deep angled tip guidewire. Patients and methods This single-arm, single-center, retrospective study included consecutive 111 patients who underwent passive loop-forming WGBC as the first biliary intervention between October 2021 and December 2022. Results WGBCs were completed within 5 minutes and overall were performed at a median papillary negotiation time of 81 seconds (interquartile range [IQR], 39-170) and 114 seconds (IQR, 49-303) in 83 (74.8%) and 106 (95.5%) cases, respectively. Logistic regression analysis identified age ≥ 80 years (odds ratio [OR]: 3.56, 95% confidence interval [CI]: 1.12-11.31) and unintentional pancreatic guidewire insertion (OR: 17.67, 95% CI: 5.75-54.31) as significant risk factors for failed WGBC within 5 minutes. Among the 106 obtained cannulations, the guidewire leading part formed a small-looped tip and wide-looped body in 83 (78.3%) and 23 (21.7%) cases, respectively. Adverse events included post-procedure pancreatitis (2/111 [1.8%]) and guidewire penetration (3/111 [2.7%]). Conclusions Passive loop-forming WGBC using an ultra-deep angled tip guidewire is a feasible procedure.

A Rare Case of New-Onset Crohn's Disease in a Patient With Chronic Palmoplantar Pustulosis.

A 44-year-old woman who had been diagnosed with palmoplantar pustulosis (PPP) at 34 years old was diagnosed with moderate Crohn's disease (CD) based on endoscopic, radiological, and pathological findings. As treatment with corticosteroids, ultraviolet, and cyclosporin had achieved partial response, PPP had been refractory in a chronic continuous state. Oral prednisolone was initially started to treat CD, but clinical remission was not achieved. Intravenous ustekinumab was subsequently started at 260 mg for clinical remission of CD. Eight weeks after starting ustekinumab, clinical remission and mucosal healing were achieved and PPP manifestations on the palms and soles were markedly improved. Ustekinumab appears to offer an effective therapeutic option for patients with PPP but has yet to be approved for this induction in Japan. CD is a rare gastrointestinal involvement in PPP patients that requires attention.

Induction Therapy With a Combination of Weekly Adalimumab Plus Intensive Granulocyte and Monocyte Adsorptive Apheresis in Patients With Ulcerative Colitis and Failure of Conventional Agents, Biologics and Janus Kinase Inhibitor.

Every-week (ew) adalimumab (ADA) maintenance following induction therapy with a standard induction regimen has recently been approved for use in Japan. The efficacy and safety of combination therapy with ew-ADA maintenance following standard induction regimen plus intensive granulocyte and monocyte adsorptive apheresis (GMA) (two sessions/week) for the treatment of refractory ulcerative colitis (UC) displaying failure of conventional, biologics and Janus kinase inhibitor have not been evaluated previously. The present retrospective study evaluated the 10-week efficacy of this combination therapy among refractory UC patients. Six patients were given initial ADA combination therapy (ADA at 160 mg in week 0, ADA 80 mg in week 2, and 40 mg in week 4, followed by ew-ADA at 40 mg/week) plus intensive GMA. One patient (16.6%) achieved clinical remission and two patients (33.3%) achieved endoscopic improvement by week 10. After excluding two patients who discontinued treatment, mean full Mayo score (P = 0.14), endoscopic subscore (P = 0.18) and C-reactive protein level (P = 0.27) at 10 weeks were numerically decreased compared with baseline in the remaining four cases, although the differences were not significant. Use of ew-ADA maintenance following standard induction regimen plus intensive GMA appears unlikely to achieve satisfactory induction of clinical remission in UC patients for whom conventional agents, biologics and Janus kinase inhibitors have failed.

Potential Risk of Misjudgment in the Decision-making Process Based on the 2018 Tokyo Guidelines in Older Patients with Acute Cholecystitis.

Objective The 2018 Tokyo Guidelines (TG18) were published to facilitate the decision-making processes (DMP), including the diagnosis and operation of acute cholecystitis (AC). However, only a few guidelines consider older adults. This study evaluated the DMP based on the TG18, focusing on older patients with AC. Methods This was a single-armed, single-center retrospective study. The primary outcome measure was the "undiagnosable" AC rate, and the secondary outcome measure was the degree of concordance of "unfit for surgery" decisions. Patients Two hundred and nine patients with AC. Results Sixty (28.7%) of 209 patients with AC were "undiagnosable" on admission based on the TG18 criteria. The numbers and rate of "undiagnosable" AC in patients ≤59, 60-79, and ≥80 years old were 4 (10.0%), 20 (24.4%), and 36 (41.4%), respectively (p<0.001). The multiple logistic regression analysis following the univariate analysis revealed that age >73 years old was the most significant risk factor for undiagnosable AC [p=0.006, odds ratio (OR): 3.06, 95% confidence interval (CI): 1.38-6.81]. Female sex (p=0.033, OR: 2.09, 95% CI: 1.06-4.09) and severe AC (p=0.049, OR: 2.97, 95% CI: 1.01-8.76) were also significant risk factors for undiagnosable AC. The number of cases unfit for surgery based on the Charlson Comorbidity Index and American Society of Anesthesiologists physical status was 90 (43.1%) and 75 (35.9%), respectively. The κ value between these 2 indicators revealed a minimal concordance of 0.33 (95% CI: 0.20-0.47). Conclusion The DMP based on the TG18 potentially harbors a misjudgment risk, especially in older patients with AC (UMIN000047715).

A Transanal Endoscopic Ultrasound-guided Fine-needle Aspiration Biopsy for an Intrapelvic Tumor Diagnosed as Recurrence of a Smooth Muscle Tumor of Uncertain Malignant Potential Following Uterine Morcellation.

A transoral endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) is a well-established tissue-sampling method. However, performing a transanal EUS-FNAB remains challenging. Uterine morcellation has emerged as a minimally invasive approach for benign tumor treatment. However, uterine myomas are heterogeneous and include malignant and indeterminate malignant cells. We herein report a rare case of intrapelvic tumor diagnosed by a transanal EUS-FNAB as a recurrence of smooth muscle tumors of uncertain malignant potential following uterine morcellation. Physicians should be aware that a previous uterine myoma resected under morcellation has the possibility of intra-abdominal recurrence. A transanal EUS-FNAB is a practical option for making a pathological diagnosis.

Upadacitinib Plus Intensive Granulocyte and Monocyte Adsorptive Apheresis for Ulcerative Colitis Achieved Ulcer Healing for Pyoderma Gangrenosum.

A 44-year-old woman who had been diagnosed with ulcerative colitis (UC) at 22 years old was diagnosed with severe flare-up of UC based on endoscopic findings associated with new-onset active pyoderma gangrenosum (PG) on both lower legs after she decided to discontinue UC treatment. Systemic treatment with intravenous prednisolone at 30 mg/day had achieved insufficient response to UC and PG, resulting in a diagnosis of corticosteroid-refractory UC and PG. Combination therapy with upadacitinib at 45 mg/day plus intensive granulocyte and monocyte adsorptive apheresis (GMA) was started to achieve clinical remission of UC. Ten weeks after starting this combination therapy, clinical improvement of UC was achieved with PG ulcer healing on both lower legs. A combination of upadacitinib plus intensive GMA may offer an effective therapeutic option for patients with active PG in addition to UC but has yet to be approved for induction or maintenance treatment of PG worldwide. PG is a dermatological involvement in UC patients that requires attention.

Depictability of the upper gastrointestinal tract on forward-viewing radial endoscopic ultrasonography versus standard upper esophagogastroduodenoscopy.

Objectives: Esophagogastroduodenoscopy (EGD) is a widely used modality for investigating the upper gastrointestinal (GI) tract, similar to endoscopic ultrasonography (EUS) for the pancreaticobiliary system. A recent and novel forward-viewing radial EUS has potential as an EGD. However, this potential has not yet been evaluated and reported in the literature. We compared the depictability of the upper GI tract on EUS using a standard EGD. Methods: This was a prospective study in a single session in an identical patient and it was conducted at a single center. Results: Sixty-nine participants were enrolled in this study. A forward-viewing radial EUS revealed equivalent visualizing performance compared with the standard EGD, except for the retroflex view of the three angular areas. Depiction scores of the anterior wall, lesser curvature, and posterior wall of the angulus in the retroflex view in the forward-viewing radial EUS were 1.94 (95% confidence interval [CI], 1.36-2.52), 2.03 (95% CI, 1.48-2.58), and 1.93 (95% CI, 1.35-2.50), respectively. These scores were significantly lower compared with those of standard EGD scores of 2.97 (95% CI, 2.86-3.08), 2.97 (95% CI, 2.86-3.78), and 2.96 (95% CI, 2.83-3.09], respectively; p < 0.001). The rate of full-mark score in these three angular areas was significantly lower in the forward-viewing radial EUS than in the standard EGD (21/69, 30.4%; 23/69, 33.3%; 21/69, 30.4% vs. 67/69; 97.1%, 67/69; 97.1%, 66/69; 95.7%, p < 0.001 for all). Conclusions: Although forward-viewing radial EUS has the potential to simultaneously investigate the upper GI and pancreaticobiliary systems, it is too early to introduce it for this purpose.

Soehendra stent retriever as a useful delivery device of drainage stent for passing an impacted cystic duct stone in a patient with acute cholecystitis.

Endoscopic transpapillary gallbladder drainage is an alternative procedure for patients with acute cholecystitis. However, this procedure is technically challenging because the drainage stent is sometimes obstructed by an impacted cystic duct stone, even if the guidewire is advanced into the gallbladder. In this report, the front end of a standard endoscopic retrograde cholangiopancreatography catheter was cut to an appropriate length as a drainage stent for transpapillary gallbladder drainage. However, this modified stent became stuck because of an impacted cystic duct stone. The Soehendra stent retriever was used as a stent delivery device in this setting. A Soehendra stent retriever with clockwise rotation was coupled with the drainage stent. Integrated devices provide a stent tip for pushability and torqueability. The stuck drainage stent at the impacted cystic duct stone resumed advancement into the gallbladder. After stent indwelling, decoupling was easy under counterclockwise rotation of the Soehendra stent retriever.