Digestive Endoscopy最新文献

{"title":"Artificial Intelligence in Cholangioscopy: Standards First, Systems Second","authors":"Marco Spadaccini, Yuichi Mori, Cesare Hassan","doi":"10.1111/den.70129","DOIUrl":"10.1111/den.70129","url":null,"abstract":"<p>The accurate characterization of indeterminate biliary strictures remains one of the most challenging tasks in therapeutic endoscopy. Despite major technological advances, including high-definition peroral cholangioscopy (POCS), diagnostic uncertainty continues to drive repeated procedures, multiple biopsies, and delayed diagnoses [<span>1, 2</span>]. Against this background, the study by Sato and colleagues [<span>3</span>] introduces a vendor-agnostic, Vision Transformer (ViT)–based artificial intelligence (AI) system for POCS image interpretation and compares its performance with both conventional convolutional neural networks and human endoscopists. This work represents an important technical step forward, but it also highlights deeper, unresolved clinical questions that the field must address.</p><p>First, the study reinforces a reality that many biliary endoscopists recognize from daily practice: human performance in biliary stricture characterization is suboptimal. Even among experts, visual interpretation of cholangioscopic findings yields only moderate diagnostic accuracy. In the present study, expert endoscopists achieved an accuracy of approximately 82% on a balanced test set, while nonexperts performed substantially worse, at around 73%. This should not be interpreted as a criticism of the individual operators involved in the study, who in fact performed adequately compared with previously published literature on this topic; rather, they reflect the inherent difficulty of biliary imaging, where subtle surface irregularities, inflammatory changes, and vascular patterns overlap between benign and malignant disease, and despite visual classification systems having been proposed [<span>4</span>], they failed in demonstrating reassuringly adequate accuracy level. In this context, the observation that an AI system can reach a level of performance comparable to experts is not trivial—it highlights the ceiling of current human interpretation and underscores why AI assistance is being actively explored.</p><p>Moreover, arguably even more important than raw accuracy is the issue of interobserver variability. In this study, the authors report suboptimal interobserver agreement among endoscopists (with lower agreement among non-experts). Also, this finding is consistent with prior literature and represents one of the most significant barriers to standardization in biliary endoscopy. Poor agreement means that the same lesion may be labeled “malignant” or “benign” depending on who is holding the scope or reviewing the images. AI systems, by contrast, offer deterministic and reproducible outputs once trained and validated. A vendor-agnostic AI, such as the ViT model proposed here, has the potential to function as a “common language” across operators, centers, and devices. With this in mind, even if AI does not dramatically outperform experts, its ability to reduce variability and harmonize decision-making may be its greatest contribution. In this","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 3","pages":""},"PeriodicalIF":4.7,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/den.70129","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147328432","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effectiveness and Safety of Enteroscopy-Assisted ERP-Guided Versus EUS-Guided Pancreatic Duct Drainage for Pancreaticojejunostomy Strictures: A Multicenter Observational Study","authors":"Shogo Ota,&nbsp;Hideyuki Shiomi,&nbsp;Yuki Fujii,&nbsp;Kazuyuki Matsumoto,&nbsp;Masataka Kano,&nbsp;Masaaki Shimatani,&nbsp;Naoki Fujita,&nbsp;Hideki Kamada,&nbsp;Saori Ueno,&nbsp;Takeshi Ogura,&nbsp;Mamoru Takenaka,&nbsp;Kae Nagao,&nbsp;Arata Sakai,&nbsp;Shuhei Shintani,&nbsp;Osamu Inatomi,&nbsp;Koh Kitagawa,&nbsp;Ryota Nakano,&nbsp;Mitsuhito Koizumi,&nbsp;Yoshiki Imamura,&nbsp;Akihisa Ohno,&nbsp;Nao Fujimori,&nbsp;Takaaki Tamura,&nbsp;Tsukasa Miyagahara,&nbsp;Mikio Nakajima,&nbsp;Masayuki Kitano","doi":"10.1111/den.70128","DOIUrl":"10.1111/den.70128","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>Enteroscopy-assisted endoscopic retrograde pancreatography-guided pancreatic duct drainage (eERP-PDD) and endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) are minimally invasive alternatives to surgery for pancreaticojejunostomy stricture (PJS); however, comparative data remain limited. We compared the effectiveness and safety of these approaches and identified factors associated with technical failure.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This multicenter retrospective study included 88 patients (111 procedures) who underwent endoscopic intervention for PJS at 13 Japanese tertiary centers. We compared clinical outcomes between eERP-PDD and EUS-PDD. The primary outcome was technical success; secondary outcomes included clinical success, procedure time, and adverse events (AEs). Propensity-score overlap weighting was used to adjust for baseline differences.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>As initial treatment, 77 patients underwent eERP-PDD and 11 underwent EUS-PDD. After adjustment, EUS-PDD achieved higher technical success (eERP-PDD, 28% vs. EUS-PDD, 71%; <i>p</i> = 0.012) and clinical success (22% vs. 71%; <i>p</i> = 0.003), with shorter procedure time (76 min vs. 41 min; <i>p</i> = 0.001). AE incidence was higher with EUS-PDD before adjustment (5% vs. 27%; <i>p</i> = 0.039) but comparable after adjustment (7% vs. 29%; <i>p</i> = 0.15); all AEs resolved with conservative management. Age &lt; 75 years, male sex, and main pancreatic duct (MPD) diameter ≥ 5 mm were independently associated with eERP-PDD failure.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>EUS-PDD demonstrated higher technical and clinical success than eERP-PDD for PJS, with comparable safety after adjustment. An MPD diameter ≥ 5 mm was associated with eERP-PDD failure. An MPD-based algorithm is proposed: eERP-PDD for MPD &lt; 5 mm with EUS-PDD as salvage, and EUS-PDD for MPD ≥ 5 mm. This algorithm is hypothesis-generating and requires prospective validation.</p>\u0000 </section>\u0000 </div>","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 3","pages":""},"PeriodicalIF":4.7,"publicationDate":"2026-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12948497/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147318983","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Efficacy and Recovery of Remimazolam Versus Midazolam in Sedated Colonoscopy: A Multicenter Randomized Controlled Trial in Japan","authors":"Daisuke Yamaguchi,&nbsp;Ryoji Ichijima,&nbsp;Hisatomo Ikehara,&nbsp;Yosuke Minoda,&nbsp;Mitsuru Esaki,&nbsp;Ayako Takamori,&nbsp;Akiyoshi Yoh,&nbsp;Moeko Shirouzu,&nbsp;Kento Sadashima,&nbsp;Yutaro Fujimura,&nbsp;Takuya Shimamura,&nbsp;Hironobu Takedomi,&nbsp;Takashi Akutagawa,&nbsp;Nanae Tsuruoka,&nbsp;Yasuhisa Sakata,&nbsp;Takuya Wada,&nbsp;Chika Kusano,&nbsp;Ryo Shimoda,&nbsp;Motohiro Esaki","doi":"10.1111/den.70130","DOIUrl":"10.1111/den.70130","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>Sedation during colonoscopy is becoming increasingly important. Remimazolam, an ultra-short-acting benzodiazepine, has a shorter pharmacokinetic half-life than that of midazolam. This study examined whether remimazolam provides superior sedation during colonoscopy in Japanese patients.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This prospective, multicenter, randomized, single-blind, controlled trial included adults (18–80 years) scheduled for sedated colonoscopy. Participants were randomized to the remimazolam and midazolam groups. The primary outcome was the proportion of ambulatory patients 5 min after colonoscopy. Secondary outcomes were successful pre-procedure sedation (Modified Observer's Assessment of Alertness/Sedation [MOAA/S] ≤ 4), recovery time, total sedative dose, and adverse events.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Forty patients were enrolled and analyzed (remimazolam, <i>n</i> = 19; midazolam, <i>n</i> = 21). At 5 min post-colonoscopy, ambulation was achieved in 100% (19/19) of remimazolam patients and 19.1% (4/21) of midazolam patients (<i>p</i> &lt; 0.0001). The median time [interquartile range (IQR)] from procedure end to full alertness (MOAA/S = 5) was 0 [0–0] min for remimazolam and 10 [5–20] min for midazolam (<i>p</i> &lt; 0.0001). The median time [IQR] from procedure end to independent ambulation was 0 [0–5] min for remimazolam and 20 [10–30] min for midazolam (<i>p</i> &lt; 0.001). Pre-procedure sedation was successful (MOAA/S ≤ 4) in 100% of both groups. The median amount [IQR] of total sedative dose was 5 [4–6] mg for remimazolam and 3 [3] mg for midazolam. Hypoxemia occurred in 5.3% and 9.5% of patients in the remimazolam and midazolam groups, respectively.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Compared with midazolam, remimazolam resulted in significantly faster recovery after colonoscopy in Japanese patients, with comparable achievement of target sedation and a low incidence of hypoxemia.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Clinical Registration</h3>\u0000 \u0000 <p>Trial number: jRCTs071240062</p>\u0000 </section>\u0000 </div>","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 3","pages":""},"PeriodicalIF":4.7,"publicationDate":"2026-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12946854/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147313152","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"From Automation to Collaboration: The Emerging Role of Artificial Intelligence in Endoscopic Reporting","authors":"Shunsuke Kamba,&nbsp;Kazuki Sumiyama","doi":"10.1111/den.70126","DOIUrl":"10.1111/den.70126","url":null,"abstract":"&lt;p&gt;For endoscopists, difficulty in recalling the exact locations or number of polyps removed after a long list of procedures is not uncommon, and discrepancies between a referring physician's report and the actual location or morphology of lesions can at times compromise treatment plans. Such discrepancies often stem not from limitations in skill or experience but from structural factors, including the pressure to complete reports quickly under heavy workloads and sustained cognitive demands. Although structured reporting has improved the quality and standardization of endoscopic documentation, it has also reduced flexibility and increased the workload, which may, in turn, contribute to burnout [&lt;span&gt;1&lt;/span&gt;].&lt;/p&gt;&lt;p&gt;A review by Sekiguchi et al. provided a comprehensive overview of artificial intelligence (AI)-assisted reporting technologies as a potential solution to these long-standing challenges. Distinct from a conventional literature review, their paper serves as a practical technology review, outlining both the current state and clinical feasibility of systems already in use, including speech recognition systems such as Voice Capture (Lasis, Osaka) and VoiceRex (NTT, Tokyo), as well as report generation tools, including AR-G1 (Fujifilm, Tokyo) and Vivoly+ (Olympus, Tokyo) [&lt;span&gt;2&lt;/span&gt;]. These platforms represent the first wave of AI-enabled endoscopic reporting, integrating speech, text, and image data to facilitate documentation.&lt;/p&gt;&lt;p&gt;Speech recognition for medical reporting has been investigated for over three decades [&lt;span&gt;3&lt;/span&gt;]. Recent studies have demonstrated that automated voice reporting can reduce documentation time by approximately 1 min per case, a modest improvement that nonetheless carries significant impact during the high-pressure operation of a busy endoscopy suite. However, widespread adoption of endoscopy remains limited. Factors such as latency, the delay between the command and system response, along with non-responsiveness or recognition errors (reported in nearly 10% of cases), remain major barriers [&lt;span&gt;4&lt;/span&gt;]. The real-time correction of these errors is particularly cumbersome during endoscopic procedures involving both hands. Conversely, in radiology, where image interpretation (reading) and reporting are generally performed retrospectively and asynchronously, allowing radiologists to review images and complete reports at a convenient time after acquisition, speech-based reporting is widely adopted in certain regions [&lt;span&gt;5&lt;/span&gt;]. With rapid advances in deep learning and large-scale language models (LLMs), speech recognition accuracy has reached human-level performance [&lt;span&gt;6&lt;/span&gt;]. Multimodal AI systems capable of simultaneously processing speech, text, and endoscopic images raise the realistic prospect of seamless, interactive documentation. Further improvements in user interface design, particularly in synchronizing spoken findings with the corresponding time points in image sequences, coul","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 2","pages":""},"PeriodicalIF":4.7,"publicationDate":"2026-02-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/den.70126","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147277994","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Endoscopist and Patients' Values and Preferences on Artificial Intelligence in Endoscopy: An Intercontinental Opinion Survey by the World Endoscopy Organization","authors":"O. F. Ahmad,&nbsp;A. de Groof,&nbsp;A. Ali,&nbsp;P. Bassett,&nbsp;M. Engels,&nbsp;S. Hoogenboom,&nbsp;N. Coelho-Prabhu,&nbsp;H. Yu,&nbsp;M. Mwachiro,&nbsp;S. Parasa,&nbsp;R. Mansilla Vivar,&nbsp;J. Mushtaq,&nbsp;H. Neumann,&nbsp;S. Thakkar,&nbsp;M. F. Byrne,&nbsp;J. E. van Hooft,&nbsp;T. Yano,&nbsp;Y. Mori","doi":"10.1111/den.70123","DOIUrl":"10.1111/den.70123","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background and Aims</h3>\u0000 \u0000 <p>Artificial intelligence (AI) is increasingly integrated into gastrointestinal (GI) endoscopy, yet limited data exist on how patients and endoscopists perceive its use. This study aimed to evaluate users' values and preferences regarding AI in endoscopy to support effective implementation and inform guideline development.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>As part of the World Endoscopy Organization (WEO) AI committee initiatives, two structured international surveys were conducted—one for patients and one for practicing endoscopists. Thirteen AI-related statements were presented to patients via an established online platform, while 23 statements were shared with endoscopists through professional networks. Responses were captured using 5-point Likert scales and analyzed with non-parametric tests, including subgroup comparisons by age, gender, and endoscopic experience.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 1237 patients and 476 endoscopists participated. Most patients supported AI in image analysis (75.5%) but emphasized the need for endoscopist oversight (92.3%). Among endoscopists, 90.3% believed AI improves endoscopy quality, and 85.3% believed it benefits outcomes. Concerns were raised about liability (47%), operator dependency (34.8%), and procedure time (49%). Most respondents felt primary responsibility for AI-related errors should rest with the endoscopist. Younger and male patients reported greater trust in AI.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Patients and endoscopists are generally supportive of AI in GI endoscopy, especially as an adjunct to human expertise. However, key concerns—including accountability, trust, and clinical integration—must be addressed to ensure responsible and effective adoption.</p>\u0000 </section>\u0000 </div>","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 2","pages":""},"PeriodicalIF":4.7,"publicationDate":"2026-02-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12921463/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146230030","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of Full Implementation of Universal Cold Snare Polypectomy for Diminutive and Small Polyps at Colonoscopy on Carbon Footprint","authors":"Hao-Yu Wu,&nbsp;Wen-Feng Hsu,&nbsp;Li-Chun Chang,&nbsp;Wei-Yuan Chang,&nbsp;Hsuan-Ho Lin,&nbsp;Chen-Ya Kuo,&nbsp;Ming-Shiang Wu,&nbsp;Han-Mo Chiu","doi":"10.1111/den.70125","DOIUrl":"10.1111/den.70125","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background and Aims</h3>\u0000 \u0000 <p>Colonoscopy significantly impacts healthcare's carbon footprint, and although cold snare polypectomy (CSP) offers a safer, more efficient method for small polyp removal, its environmental impact remains unclear. This study compares carbon footprints between the forceps plus hot snare polypectomy (HSP) versus the universal CSP strategy for subcentimetric polyps.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This retrospective analysis compared two distinct polypectomy strategies: forceps plus HSP, involving biopsy removal for diminutive adenomas and HSP for small adenomas, and universal CSP for adenomas smaller than 10 mm. A life cycle assessment evaluated the environmental impacts of endoscopy procedures, with parameters obtained from our previous pragmatic trial and empirical hospital data in 2022. Sensitivity analyses were conducted to assess the robustness of greenhouse gas (GHG) emissions estimates.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The universal CSP strategy generated 22.08 kg of carbon dioxide equivalents (CO₂e) per colonoscopy, a 5.30% (95% CI 4.71%–5.89%) reduction compared with 23.32 kg CO₂e for the forceps plus HSP strategy. Based on 15,177 colonoscopies performed in 2022, including 5599 polypectomies, transitioning to universal CSP would reduce an institution's annual GHG emissions by an estimated 6915 kg CO₂e.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Adopting a universal CSP strategy for subcentimetric polyps offers a significant environmental benefit alongside established clinical advantages. This single transition could cut procedural emissions by over 5% and substantially reduce the annual carbon footprint of endoscopy units, equivalent to the emissions from over 19,700 miles of passenger car travel. Our findings establish CSP as a key strategy for promoting sustainable healthcare.</p>\u0000 </section>\u0000 </div>","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 2","pages":""},"PeriodicalIF":4.7,"publicationDate":"2026-02-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146215044","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Minor Papilla Pancreatic Duct Drainage Using a Novel Device Delivery System and Internalization of Endoscopic Nasal Pancreatic Drainage Tube With a Loop Cutter for Pancreatic Pleural Fistula in a Patient With Pancreatic Divisum","authors":"Takafumi Mie,&nbsp;Tsuyoshi Takeda,&nbsp;Naoki Sasahira","doi":"10.1111/den.70118","DOIUrl":"10.1111/den.70118","url":null,"abstract":"<p>Pancreatic pleural fistula (PPF) is a rare but potentially life-threatening complication. It is most associated with chronic pancreatitis [<span>1</span>], whereas pancreatic cancer–related PPF is uncommon. Although endoscopic treatment has been reported to be effective for PPF [<span>2</span>], pancreatic duct drainage in cases with pancreatic divisum remains technically challenging [<span>3</span>]. Although the usefulness of stent placement using a novel designed device delivery system (EndoSheather; Piolax Medical Device, Kanagawa, Japan) [<span>4</span>] and internalization of endoscopic nasal biliary drainage tube using a loop cutter [<span>5</span>] have been reported, there are no reports describing their use for pancreatic duct drainage.</p><p>A 67-year-old woman receiving chemotherapy for pancreatic cancer developed rupture of a pancreatic pseudocyst one month after chemotherapy initiation. Two months later, massive left-sided pleural effusion developed, and the patient was admitted to the hospital with dyspnea. A chest tube was inserted, and fluid analysis showed elevated amylase levels (&gt; 60,000 IU/L). Previous computed tomography demonstrated a pancreatic duct stricture in the pancreatic body and pancreatic divisum (Figure 1).</p><p>Endoscopic retrograde cholangiopancreatography was performed, and cannulation of the minor papilla was achieved. However, advancement of the catheter and 5-Fr endoscopic nasal pancreatic drainage (ENPD) tube beyond the stricture was difficult. Then, a device delivery system enabled passage through stricture. The ENPD tube was advanced through the device, enabling placement of the ENPD tube beyond the stricture. The chest tube was removed 5 days after ERCP, and the ENPD tube was internalized 1 week later using a loop cutter. No procedure-related adverse events occurred, and PPF did not recur (Figure 2, Video S1).</p><p>When an ENPD tube placement is difficult due to severe pancreatic duct stricture, especially with pancreatic divisum, the use of a device delivery system allows reliable placement of an ENPD tube across the stricture and internalization of an ENPD tube with a loop cutter may be useful.</p><p>Conception: T.M. and T.T.; acquisition: T.M.; drafting the work: T.M.; revising: T.T. and N.S.; final approval: N.S.; all authors have read and agreed to the published this version of the manuscript.</p><p>The authors have nothing to report.</p><p>The authors declare no conflicts of interest.</p>","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 2","pages":""},"PeriodicalIF":4.7,"publicationDate":"2026-02-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/den.70118","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146222123","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"What Are the Future Research Priorities Regarding Biliary Cannulation? How Can It Be Mastered? What Is the Most Crucial Factor?","authors":"Mamoru Takenaka,&nbsp;Masatoshi Kudo","doi":"10.1111/den.70093","DOIUrl":"10.1111/den.70093","url":null,"abstract":"&lt;p&gt;Biliary cannulation is a fundamental technique in endoscopic retrograde cholangiopancreatography (ERCP) and is essential for all therapeutic and diagnostic procedures associated with ERCP. ERCP-related procedures have made remarkable progress over more than 50 years since their development, benefiting from innovations in techniques and device development [&lt;span&gt;1, 2&lt;/span&gt;]. However, failure to achieve biliary cannulation renders further procedures impossible. Prolonged biliary cannulation time is a high-risk factor for post-ERCP pancreatitis (PEP) and may adversely affect patient prognosis [&lt;span&gt;3&lt;/span&gt;].&lt;/p&gt;&lt;p&gt;Therefore, mastering biliary cannulation is the primary objective for endoscopists performing ERCP; however, it remains a significant challenge, and achieving a success rate exceeding 95% remains unresolved. With increasing experience, most endoscopists can eventually succeed in biliary cannulation. However, endoscopists who perform biliary cannulation without establishing a strategy and without evidence will never be able to overcome difficult cases. Cannulation of a native or intact papilla fails in approximately 5%–11% of cases, even in experienced hands [&lt;span&gt;4, 5&lt;/span&gt;].&lt;/p&gt;&lt;p&gt;One of the main reasons for this challenge is the lack of a standardized technique and uniform teaching methods for biliary cannulation. Cannulation techniques include contrast-assisted, guidewire-assisted, and hybrid approaches. When initial attempts fail, multiple rescue techniques such as the double-guidewire (DGW) technique or precut sphincterotomy can be employed. Preferences for these techniques vary among both trainees and trainers, resulting in a biased and heterogeneous transfer of skills. This variability makes the creation of comprehensive, universally accepted guidelines difficult, and such guidelines remain insufficient.&lt;/p&gt;&lt;p&gt;In latest digestive endoscopy, new guidelines led by the World Endoscopy Organization (WEO), involving expert panels from Asia, Europe, and the United States, have been published [&lt;span&gt;6&lt;/span&gt;]. The most distinctive feature of this guideline is their aim to provide globally applicable clinical recommendations, regardless of available resources or expertise. The guideline developers paid particular attention to integrating all available techniques for biliary cannulation, making it a clinically practical and useful resource worldwide.&lt;/p&gt;&lt;p&gt;The document is structured around four major themes: prevention of PEP, biliary cannulation techniques, endoscopic sphincterotomy and balloon dilation, and cannulation in special situations. Fourteen clinical questions (CQs) were formulated, each accompanied by a statement and supporting evidence. Although the explanations are concise, they incorporate extensive evidence, providing valuable insights into the current evidence-based status of biliary cannulation.&lt;/p&gt;&lt;p&gt;One of the most appealing features of these guidelines is the comprehensive summary of meta-analyses of randomized c","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 2","pages":""},"PeriodicalIF":4.7,"publicationDate":"2026-02-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12912949/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146215087","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Toward a Standardized Severity Assessment in Intestinal Behçet's Disease: Reflections on the Proposal of the SCIBD Criteria","authors":"Teppei Omori","doi":"10.1111/den.70124","DOIUrl":"10.1111/den.70124","url":null,"abstract":"&lt;p&gt;Behçet's disease (BD) is a complex multi-organ inflammatory disorder characterized by recurrent oral aphthous ulcers, ocular lesions, genital ulcers, skin manifestations, and various systemic symptoms. Among its clinical manifestations, intestinal BD poses significant therapeutic challenges owing to its diverse symptoms, unpredictable disease course, and potential for serious complications, such as perforation and massive bleeding. Accurate and rapid assessment of disease severity is crucial to make effective treatment strategy decisions and predict patient prognosis.&lt;/p&gt;&lt;p&gt;A recent multicenter study by Fukui et al. [&lt;span&gt;1&lt;/span&gt;] represents an important step toward standardizing disease severity assessment. The authors proposed new severity criteria for intestinal Behçet's disease (SCIBD) based on five parameters: abdominal pain, abdominal tenderness, intestinal bleeding, serum C-reactive protein (CRP) levels, and endoscopic findings. They validated the clinical utility in a nationwide cohort comprising 14 institutions across Japan. This study represents the first attempt to integrate an objective endoscopic assessment of intestinal BD into a formal severity classification system, bridging the gap between clinical symptoms, biomarker values, and treatment decisions.&lt;/p&gt;&lt;p&gt;The SCIBD criteria provide a framework for the clinical evaluation of intestinal BD. Although the conventional disease activity index for intestinal Behçet's disease (DAIBD) [&lt;span&gt;2&lt;/span&gt;, pp. 605–613] is a useful tool for assessing disease activity, it is primarily symptom-based and lacks elements for endoscopic evaluation. Fukui et al. addressed this limitation by incorporating endoscopic ulcer grades into the definition of ulcer severity: grade 1 (aphthae and ulcers &lt; 1 cm), grade 2 (well-demarcated shallow ulcers ≥ 1 cm), and grade 3 (deep [mining] ulcers). Deep [mining] ulcers, characteristic of intestinal-type BD, are key indicators of severe disease. This approach is critically important because it emphasizes direct visualization of mucosal lesions. This is because deep ulcers are known predictors of poor prognosis and complications such as perforation [&lt;span&gt;3&lt;/span&gt;, pp. 635–640].&lt;/p&gt;&lt;p&gt;The main findings of this study were the consistent correlations between the severity classification based on the SCIBD and established inflammatory markers such as CRP, erythrocyte sedimentation rate, serum albumin, and DAIBD score. Importantly, the treatment patterns aligned with the defined severity based on the SCIBD. Anti-TNF-α therapy was more frequently used in severe cases (49.4%) than in moderate cases (20.8%), and surgical intervention was more common in patients classified as severe. These findings are consistent with current treatment guidelines that recommend more aggressive therapy for severe cases [&lt;span&gt;4&lt;/span&gt;, pp. 679–700].&lt;/p&gt;&lt;p&gt;Furthermore, the multicenter retrospective study design involving 146 patients, including those with intestinal BD and simple ulce","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 2","pages":""},"PeriodicalIF":4.7,"publicationDate":"2026-02-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/den.70124","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146215102","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reply: Reappraisal of Confounding and Detection Bias in the Gastric Atrophy–ESCC Association","authors":"Kenta Watanabe,&nbsp;Sho Fukuda,&nbsp;Katsunori Iijima","doi":"10.1111/den.70127","DOIUrl":"10.1111/den.70127","url":null,"abstract":"<p>We appreciate Park's thoughtful commentary on our nationwide cohort showing that extensive (open-type) endoscopic gastric atrophy (GA) is associated with higher esophageal squamous cell carcinoma (ESCC) incidence among regular screening esophagogastroduodenoscopy (EGD) examinees in Japan [<span>1, 2</span>].</p><p>Residual and unmeasured confounding warrant consideration. In our health check-up setting, smoking and alcohol were recorded as ever/never per the Ministry of Health, Labour and Welfare's standard questionnaire, which lacks cumulative exposure items, an acknowledged limitation [<span>2, 3</span>]. Even so, alcohol remained significantly associated with ESCC, and open-type GA consistently emerged as an independent risk factor (adjusted HR 2.7, 95% CI 1.6–4.7). We agree that diet, oral hygiene and socioeconomic context are relevant; future prospective designs should capture quantitative exposures and these variables systematically.</p><p>To address baseline imbalances (age, sex), we combined multiple imputation with multivariable Cox regression and prespecified subgroup analyses, adjusting for age, sex, alcohol, smoking, etc. Findings were concordant across imputed and complete case analyses and subgroups. Propensity-based methods were considered a priori but deprioritized due to few ESCC events (<i>n</i> = 77) and a three-category exposure, which risked unstable weights or loss of effective sample size.</p><p>Regarding detection bias, baseline GA was adjudicated independent of outcomes, incidence was expressed per person-years, and time-to-event modeling accounted for follow-up. Even in a sensitivity model additionally adjusting for the number of EGDs during follow-up, the association for open-type GA was materially unchanged (adjusted HR 2.80, 95% CI 1.64–4.80), supporting robustness.</p><p>Mechanistically plausible pathways (hypochlorhydria and oral–esophageal microbial influences) merit integrative prospective studies (microbiome, metabolomics, reflux characterization). In summary, within a large screening cohort, open-type GA remained an independent risk marker for ESCC. While residual confounding cannot be fully excluded, complete negation of the association appears unlikely; our study is hypothesis-generating and could motivate mechanistic research.</p><p>K.W. drafted the manuscript; S.F. and K.I. critically revised it. All authors approved the final version.</p><p>The authors have nothing to report.</p><p>The authors declare no conflicts of interest.</p>","PeriodicalId":159,"journal":{"name":"Digestive Endoscopy","volume":"38 2","pages":""},"PeriodicalIF":4.7,"publicationDate":"2026-02-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12909645/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146208496","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}