Clinical Endoscopy

Reviews

Undifferentiated-type early gastric cancer: from margin demarcation to complete resection: Satoru Mizutani, Seiichiro Abe, Yutaka Saito; Received February 17, 2026 Accepted May 8, 2026 Published online August 10, 2026; DOI: https://doi.org/10.5946/ce.2026.062 [Epub ahead of print]

Abstract PDF: Gastric cancer remains a major global health burden, particularly in Asia, where widespread implementation of endoscopic screening has increased the detection of early gastric cancer (EGC). With advances in endoscopic techniques, endoscopic resection (ER), especially endoscopic submucosal dissection, has become the standard treatment for EGC with a negligible risk of lymph node metastasis (LNM). Undifferentiated-type EGC (UD-EGC) is associated with a higher risk of LNM than differentiated-type EGC. However, favorable long-term outcomes can be achieved with curative resection. Despite this, accurate endoscopic detection, characterization, and delineation of UD-EGC remain a challenge because of their subtle morphology and unique growth pattern. Image-enhanced endoscopy, particularly magnifying endoscopy with narrow-band imaging, plays an important role in diagnosis and assessment of the lateral extent of the lesion. In Japan, accumulating evidence, including prospective multicenter trials, has led to the classification of intramucosal UD-EGC ≤2 cm without ulceration, as an absolute indication for ER in the latest clinical guidelines. Short and long-term outcomes after curative ER for UD-EGC are comparable to those after surgical resection. This review summarizes the current literature on the diagnosis and endoscopic management of UD-EGC, providing a comparative overview of differences in endoscopic treatment recommendations among international guidelines.

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Latest advancements in endoscopic palliative care for patients with pancreatic cancer: Raquel Gonçalves, Joel Silva, Eduardo Rodrigues-Pinto; Clin Endosc 2026;59(4):497-509. Published online April 28, 2026; DOI: https://doi.org/10.5946/ce.2025.227

Abstract PDF: Pancreatic cancer is a major cause of cancer-related mortality and is frequently diagnosed at advanced stages when surgery is no longer an option. Most patients require palliative care to manage symptoms, such as jaundice, pain, and gastric outlet obstruction (GOO). Therapeutic endoscopic options, including endoscopic ultrasound (EUS)-guided techniques, have become essential for improving quality of life. We conducted a literature review focusing on the current palliative endoscopic therapy options for advanced pancreatic cancer. Malignant biliary obstruction is primarily treated using endoscopic retrograde cholangiopancreatography. However, when this method is complex or unsuccessful, EUS-guided biliary drainage is considered a reliable and safe alternative. Irradiating stents may increase stent patency times and patient survival. EUS-guided gastroenterostomy, if technical expertise is available, is becoming the first option for GOO in patients with longer survival, with enteral stenting being preferred for patients with limited life expectancies or when the EUS option is not available. Although EUS-guided celiac plexus neurolysis and pancreatic duct drainage play a role in pain management, EUS-guided radiofrequency ablation remains under investigation. In conclusion, endoscopic and EUS-guided interventions provide safe, minimally invasive, and highly effective approaches for the palliative care of pancreatic cancer, enhancing patients’ quality of life and minimizing the need for more invasive surgical procedures.

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Original Articles

A pilot study of a novel tapered and flared fully covered self-expandable metal stent for unresectable malignant distal biliary obstruction: a multicenter study in Japan: Toji Murabayashi, Makoto Kobayashi, Keisuke Iwata, Yuhei Iwasa, Yujiro Kawakami, Yoshiharu Masaki, Shinya Kawaguchi, Hayato Nakagawa; Clin Endosc 2026;59(3):425-432. Published online April 23, 2026; DOI: https://doi.org/10.5946/ce.2025.399

Graphical Abstract Abstract PDF

Background
/Aims: This study evaluated the feasibility and clinical outcomes of a novel tapered and flared, fully covered, self-expandable metal stent (TF-FCSEMS) for unresectable malignant distal biliary obstruction (UMDBO).
Methods
This multicenter retrospective study included 40 patients who underwent transpapillary placement of a TF-FCSEMS (10-mm cylindrical body with an 8-mm tapered distal end) for UMDBO between May 2023 and July 2024. The primary outcome was time to recurrent biliary obstruction (TRBO). Secondary outcomes included technical and clinical successes, adverse events (AEs), and overall survival.
Results
Technical and clinical success rates were 100% and 98%, respectively. During a median follow-up period of 271 days, recurrent biliary obstruction (RBO) occurred in 10 (26%) of the 39 patients who achieved clinical success. The median TRBO was 539 days (95% confidence interval, 389–not reached), and the non-RBO rates at 3, 6, and 12 months were 94%, 71%, and 61%, respectively. Symptomatic stent migration occurred in 2 patients (5.1%), while asymptomatic migration was observed in 3 (7.7%). Post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in four patients (10%). Non-occlusion cholangitis developed in five (13%) patients, mostly with tumor-related duodenal stenosis. All AEs were managed conservatively or endoscopically.
Conclusions
TF-FCSEMS appears to be a feasible and acceptable treatment option for UMDBO. Further prospective studies are required to confirm these findings.

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Beyond cylindrical stents: does a tapered-and-flared design improve biliary drainage?
Woo Hyun Paik
Clinical Endoscopy.2026; 59(3): 406. CrossRef

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Echoendoscopic evaluation of the vascular pattern of solid pancreatic lesions as a predictor of neuroendocrine neoplasms: a retrospective study in Mexico: Edgardo Amaya-Fragoso, José Guillermo de la Mora-Levy, Uriel Isaías Martín-Flores; Clin Endosc 2026;59(3):450-458. Published online April 23, 2026; DOI: https://doi.org/10.5946/ce.2025.338

Graphical Abstract Abstract PDF

Background
/Aims: Endoscopic ultrasonography (EUS) is essential for evaluating solid pancreatic lesions (SPL). Pancreatic neuroendocrine neoplasms (pNEN) account for 2% of SPL and typically show hypervascularity. This study aimed to assess whether a specific vascular pattern could predict pNEN.
Methods
Patients who underwent EUS for a SPL and were histologically diagnosed with pNEN were included. Tissues were obtained using endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) and/or surgical resection. Power Doppler was used to assess the vascular patterns. Patients with pNEN were compared to those diagnosed with pancreatic ductal adenocarcinoma during the same period. Group comparisons by size and histological grade were performed using the chi-square test. Logistic regression analysis identified the EUS features associated with pNEN.
Results
Among 125 patients (43 pNEN), a peripheral vascular rim (PVR) was associated with pNEN (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.7–8.5; p=0.03), with 100% specificity. Hypervascularity (OR, 3.8; 95% CI, 1.1–13.4; p=0.03) and pancreatic atrophy (OR, 0.3; 95% CI, 0.1–0.9; p=0.04) were also associated.
Conclusions
PVR demonstrated 100% specificity and 34.9% sensitivity for pNEN diagnosis, serving as a rule-in sign. PVR visualization may aid in differential diagnosis when EUS-FNB is unavailable or inconclusive.

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Peripheral vascular rim on endoscopic ultrasound as a practical rule-in sign for pancreatic neuroendocrine neoplasms
Eunae Cho
Clinical Endoscopy.2026; 59(3): 403. CrossRef

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Reviews

Underwater endoscopic submucosal dissection in the gastrointestinal tract: technical review and dual-approach endoscopic submucosal dissection: Mitsuru Nagata; Received September 7, 2025 Accepted November 8, 2025 Published online March 17, 2026; DOI: https://doi.org/10.5946/ce.2025.330 [Epub ahead of print]

Abstract PDF: Endoscopic submucosal dissection (ESD) has become an established technique for en bloc resection of superficial gastrointestinal neoplasms. However, conventional ESD (CESD) under gas insufflation remains technically demanding, particularly in gravity-side lesions or in cases with submucosal fibrosis. Underwater ESD (UESD) was developed to overcome these challenges. Complete submergence mitigates gravity-related difficulties, enhances visualization through the natural zoom effect, and facilitates submucosal dissection via buoyancy and water pressure. Retrospective data further suggest that UESD may reduce the risk of post-ESD coagulation syndrome, which is likely attributable to the heat sink effect. UESD can also be integrated with device-assisted traction and pocket creation methods. However, limitations, such as visual field impairment caused by bleeding or bubble formation, remain concerns, and their optimal management requires further investigation. Nevertheless, UESD allows procedural flexibility by switching between UESD and CESD within the same procedure, herein referred to as dual-approach ESD. Despite its routine use in clinical practice, dual-approach ESD has not been clearly distinguished from UESD in most clinical studies, complicating comparisons with CESD. To advance both clinical practice and research, future investigations should clearly differentiate UESD from dual-approach ESD for a more accurate evaluation. Furthermore, appropriate procedural selection requires careful consideration of multiple factors.

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Current role of endoscopic ablation in the management of pancreatic cancer: Tae In Kim, Jonghyun Lee, Ho Seung Lee, Sung Yong Han, Jae Min Lee; Received July 4, 2025 Accepted December 11, 2025 Published online March 16, 2026; DOI: https://doi.org/10.5946/ce.2025.216 [Epub ahead of print]

Abstract PDF: Pancreatic cancer remains one of the most challenging malignancies to treat, with its incidence steadily rising owing to factors such as aging populations, lifestyle changes, and improved diagnostic capabilities. Surgery is an essential treatment; however, most patients are diagnosed at advanced stages. Conventional therapies offer limited survival benefits, underscoring the need for innovative approaches. Local treatments have emerged as critical strategies for improving tumor control and patient outcomes, particularly in unresectable or metastatic cases. Recent advancements include refinements in radiofrequency ablation (RFA), stereotactic body radiotherapy, irreversible electroporation, cryotherapy, and brachytherapy. RFA is a well-known modality that has been used effectively for the treatment of solid tumors such as hepatocellular cancer and cholangiocarcinoma. Cryotherapy offers targeted ablation with extreme cold, minimizing damage to surrounding tissues, whereas brachytherapy delivers localized radiation with precision, enhancing efficacy and reducing systemic toxicity. Nanoparticle-based drug delivery systems are an emerging trend in immunotherapy and advanced imaging techniques. This review evaluates advancements and declines in local treatments for unresectable pancreatic cancer. It underscores the importance of addressing rising pancreatic cancer rates through personalized approaches, robust clinical trials, and multidisciplinary collaboration to optimize therapeutic outcomes.

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Systematic Review and Meta-analysis

Enhanced adenoma detection with Endocuff Vision: a GRADE assessed systematic review and meta-analysis: Ahmed Ali Khan, Fariha Hasan, Mohammed Dheyaa Marsool Marsool, Muhammad Uzair, Kanz Ul Eman Maryam, Muhammad Usman Babar, Mutahhar Talha, Haider Imran, Rayyan Mohammad Makki Bakhsh, Kalsoom Zulfiqar, Fatima Wahid, Amal Shahzad Khan, Daniel Ashraf Guirguis, Christina Tofani, Anthony Infantolino; Clin Endosc 2026;59(3):371-385. Published online February 2, 2026; DOI: https://doi.org/10.5946/ce.2025.163

Graphical Abstract Abstract PDF Supplementary Material: Background
/Aims: Colorectal cancer (CRC) is the second leading cause of cancer-related deaths and the third most common cancer worldwide. Detecting adenomas during colonoscopy reduces the CRC risk, with higher adenoma detection rates (ADRs) correlating with lower CRC incidence and mortality. Endocuff Vision (EV) enhances mucosal visualization and may improve ADRs.
Methods
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, PubMed, Embase, and Cochrane databases were searched through April 2025 for studies comparing EV-assisted and standard colonoscopy. The primary outcomes of interest were the ADRs, polyp detection rates (PDRs), and adverse events (AEs). Outcomes were pooled using a random-effects meta-analysis model and are presented as risk ratios (RRs) and mean differences. Heterogeneity in the pooled outcomes was assessed using the Higgins I².
Results
Thirty-four studies (43,702 participants) were included. EV significantly improved ADRs (RR, 1.15; 95% confidence interval [CI],1.07–1.25) and PDRs (RR, 1.16; 95% CI, 1.10–1.23). EV also improved lesion detection in the left colon (RR, 1.23; 95% CI, 1.11–1.35) and right colon (RR, 1.19; 95% CI, 1.09–1.29). No significant improvement was observed in advanced ADRs or cecal intubation. EV use was associated with more AEs.
Conclusions
EV-assisted colonoscopy improved ADRs and PDRs in both colonic regions and enhanced CRC screening despite increased AEs.

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Original Article

Clinical efficacy of endoscopic resection for subepithelial tumors in the esophagogastric junction and gastric cardia: an observational study: Sang Jin Park, Min A Yang, Jae Sun Song, Won Dong Lee, Myoung Jin Ju, Jin Woong Cho; Clin Endosc 2026;59(2):245-253. Published online January 7, 2026; DOI: https://doi.org/10.5946/ce.2025.219

Graphical Abstract Abstract PDF

Background
/Aims: Gastric subepithelial tumors (SETs) located near the esophagogastric junction (EGJ) are difficult to treat surgically and endoscopically. This study aimed to evaluate the effectiveness and safety of endoscopic resection of SETs growing from the muscularis propria located in the EGJ and gastric cardia.
Methods
This study included 26 consecutive patients who underwent endoscopic resection of 27 gastric SETs between November 2012 and May 2023.
Results
Of the 27 gastric SETs, 3 and 24 were located in the EGJ and gastric cardia, respectively. The mean tumor size, operative time, and duration of hospitalization were 21 (6–52) mm, 35.4 (9–65) minutes, and 4.2 (3–7) days, respectively. Endoscopic resection of the SETs achieved an en bloc resection rate of 100% (27/27) and a complete resection rate of 88.9% (24/27). Pathological examination confirmed four gastrointestinal stromal tumors and 23 leiomyomas. No bleeding, peritonitis, or abdominal infection occurred after the endoscopic resections. Residual lesions were identified in three patients (11.1%). No recurrence was observed during follow-up (range, 3–24 months).
Conclusions
SETs in the EGJ and gastric cardia can be resected effectively, even if they originate from the muscularis propria layer.

Citations

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Endoscopic resection for gastric subepithelial lesions: overtreatment or the next step in optimization?
Chen-Shuan Chung
Clinical Endoscopy.2026; 59(2): 234. CrossRef
A pilot study on the application and efficacy of mucosal traction-assisted clip closure in endoscopic full-thickness resection for gastric submucosal tumors
Qian Zhang, Fengcheng Zang, Jie Xu, Yunfu Feng, Zhibing Wang, Chao Ma, Luojie Liu, Xianjing Fan, Qiushi Tian
Scientific Reports.2026;[Epub] CrossRef

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Review

Non-invasive colorectal cancer screening: emerging tools and clinical evidence: Hyoung Il Choi, Jae Myung Cha; Received July 28, 2025 Accepted September 12, 2025 Published online December 3, 2025; DOI: https://doi.org/10.5946/ce.2025.246 [Epub ahead of print]

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