Asada S, Kitagawa K, Hanatani J, Motokawa Y, Osaki Y, Iwata T, Kaji K, Mitoro A, Nagai M, Yoshiji H, Sho M. Endoscopic biliary drainage with multi-hole self-expandable metallic stent during neoadjuvant chemoradiotherapy in pancreatic cancer. World J Gastrointest Endosc 2025; 17(11): 111107 [PMID: 41256302 DOI: 10.4253/wjge.v17.i11.111107]
Corresponding Author of This Article
Koh Kitagawa, MD, PhD, Department of Gastroenterology, Nara Medical University, 840 Shijou-cho, Kashihara 634-8522, Nara, Japan. kitagawa@naramed-u.ac.jp
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Author contributions: Kitagawa K, Asada S contributed to conceptualization; Hanatani J, Motokawa Y, Osaki Y, Iwata T, Kaji K contributed to data curation; Hanatani J, Motokawa Y, Osaki Y, Iwata T, Kaji K, Nagai M, Mitoro A contributed to investigation; Kitagawa K, Asada S contributed to methodology, project administration, resources, visualization, validation, writing the original draft; Yoshiji H, Sho M contributed to writing review and editing, supervision.
Institutional review board statement: This single-center retrospective study was approved by the Nara Medical University Ethics Committee (4018).
Informed consent statement: This retrospective observational study does not contain identifiable personal information. We published details about the study on our website to allow patients to opt out if they wish.
Conflict-of-interest statement: Koh Kitagawa has received a speaker honorarium from Boston Scientific Japan. Koh Kitagawa has received a consulting fee from M.I. Tech.
Data sharing statement: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Koh Kitagawa, MD, PhD, Department of Gastroenterology, Nara Medical University, 840 Shijou-cho, Kashihara 634-8522, Nara, Japan. kitagawa@naramed-u.ac.jp
Received: June 24, 2025 Revised: August 10, 2025 Accepted: September 16, 2025 Published online: November 16, 2025 Processing time: 144 Days and 6.8 Hours
Abstract
BACKGROUND
Neoadjuvant therapy (NAT) for pancreatic cancer (PC) is becoming standardized, with neoadjuvant chemoradiotherapy (NACRT) showing proven effectiveness. However, the optimal endoscopic biliary drainage approach during NAT remains controversial. In this single-center retrospective case series, we report the use of a novel multi-hole self-expandable metallic stent (MH-SEMS) for preoperative biliary drainage during NACRT in patients with PC.
AIM
To assess the feasibility of endoscopic biliary drainage using MH-SEMS during NACRT in patients with malignant distal biliary obstruction secondary to resectable and borderline resectable PC.
METHODS
We included 14 patients—10 with resectable, 2 with borderline resectable, and 2 with unresectable locally advanced disease—who had undergone surgery after biliary drainage using MH-SEMS (diameter: 10 mm). Clinical and technical success was achieved in all patients, with a median interval of 105 days between stent placement and surgery.
RESULTS
A partial response was observed in five patients (35.7%), whereas nine patients (64.3%) exhibited stable disease. Only one patient (7.1%) developed moderate cholangitis from recurrent biliary obstruction caused by sludge 337 days after stent placement during systemic chemotherapy, requiring MH-SEMS replacement. Pathological examination of postoperative specimens revealed tumor shrinkage in many cases, and no stent migration was observed. Adverse events included mild pancreatitis in two patients (14.3%) and moderate pancreatitis in one patient (7.1%), as defined by the Tokyo Criteria 2024.
CONCLUSION
No cases of cholecystitis, liver abscess, or hemorrhage were reported. No disadvantages in surgical procedures or postoperative complications related to MH-SEMS placement were observed.
Core Tip: We investigated the usefulness of a novel multi-hole self-expandable metallic stent (MH-SEMS) for preoperative biliary drainage during neoadjuvant chemoradiotherapy (NACRT) in patients with pancreatic cancer (PC). We included 14 patients who underwent surgery following biliary drainage using MH-SEMS. Clinical and technical success were achieved in all patients. The median interval between stent placement and surgery was 105 days. Only one patient (7.1%) experienced recurrent biliary obstruction caused by sludge. MH-SEMS placement is a potentially effective treatment option for preoperative biliary drainage in patients with PC undergoing NACRT.
Citation: Asada S, Kitagawa K, Hanatani J, Motokawa Y, Osaki Y, Iwata T, Kaji K, Mitoro A, Nagai M, Yoshiji H, Sho M. Endoscopic biliary drainage with multi-hole self-expandable metallic stent during neoadjuvant chemoradiotherapy in pancreatic cancer. World J Gastrointest Endosc 2025; 17(11): 111107
Pancreatic cancer (PC) has a poor prognosis, and multidisciplinary treatment is necessary to improve outcomes. Previously, the efficacy of preoperative treatment for resectable PC (R-PC) was unclear. However, recent randomized controlled trials have revealed that neoadjuvant chemotherapy with gemcitabine and S-1 prolongs survival of patients with R-PC[1]. Japanese guidelines recommend neoadjuvant therapy (NAT) even for R-PC[2]. Neoadjuvant chemoradiotherapy (NACRT) has also been reported to be effective for R-PC and borderline R-PC (BR-PC)[3-6]. Furthermore, total NAT (TNT), which combines systemic chemotherapy and NAT, may be a useful treatment option for BR-PC[7].
A common complication of pancreatic head cancer is obstructive jaundice caused by malignant distal biliary obstruction (MDBO). In upfront surgery, the need for biliary drainage remains controversial, even in cases of obstructive jaundice. However, in patients with R-PC or BR-PC undergoing preoperative treatment, the interval before surgery is prolonged, making safe and efficient biliary drainage during NAT or TNT crucial. The latest Japanese PC treatment guidelines recommend self-expandable metallic stent (SEMS) placement for preoperative drainage, as it reduces the frequency of recurrent biliary obstruction (RBO)[2]. However, the incidence of adverse events (AEs), such as cholecystitis and pancreatitis, is higher with SEMSs than with plastic stents (PSs)[8]. Furthermore, there are concerns that SEMS placement near the surgical site may complicate surgery by hindering tumor and tissue resection. Additionally, although SEMSs are often of the fully covered type (FC-SEMSs), which can be removed and replaced, they tend to migrate when the tumor shrinks in response to anticancer therapy, including NAT[9]. Thus, currently, the optimal biliary drainage approach, as NAT for PC becomes standardized, remains controversial. In particular, biliary drainage during NACRT is insufficiently studied[10-13], and no consensus exists regarding the optimal stent.
Recently, the multi-hole SEMS (MH-SEMS), featuring a covered membrane with multiple small side holes, has been reported to be useful in patients with unresectable MDBO[14-17]. Although the reported stent patency varies, migration is less likely because the bile duct mucosa embeds in the stent through the side holes[18]. In our previous study of MH-SEMS in patients with unresectable PC[17], removing and replacing the stent were possible, with a low incidence of cholecystitis. Thus, MH-SEMS may be suitable for preoperative drainage in patients with PC complicated with MDBO.
MATERIALS AND METHODS
Study population
We enrolled 84 patients who underwent MH-SEMS for MDBO caused by PC at our hospital between April 2023 and March 2025. Of these patients, 70 did not undergo surgery because of advanced PC stage, severe comorbidities, or refusal of surgery and were excluded from this study. Figure 1 shows the patient flowchart for this study. Ten patients were diagnosed with R-PC; three underwent MH-SEMS placement as initial biliary drainage, whereas seven required reintervention for early PS obstruction before starting NACRT. All patients with R-PC underwent curative surgery after NACRT. Two patients with BR-PC underwent MH-SEMS placement as initial biliary drainage and were first treated with systemic chemotherapy. Subsequently, these patients underwent NACRT (TNT) followed by curative surgery. Furthermore, two patients were initially diagnosed with unresectable locally advanced PC (UR-LAPC). Particularly, the tumor involved the celiac artery at an angle exceeding 180° in one patient and involved the superior mesenteric artery in the other patient. They underwent MH-SEMS placement as initial biliary drainage and were initially treated with systemic chemotherapy, followed by NACRT (TNT) and subsequent curative surgery.
Ethical approval was obtained from the Nara Medical University Ethics Committee (Approval No.: 4018). Written informed consent was not required for this study, as only anonymized data were used. The Ethics Committee approved an opt-out method in which study information was disclosed on the hospital website, and patients were given the opportunity to decline participation.
Outcome measurement
We measured outcomes as follows: The incidence of RBO during NACRT/TNT in patients with PC who underwent surgery after MH-SEMS placement, stent-related AE (acute pancreatitis, acute cholecystitis, non-stent obstructive cholangitis, bleeding, or perforation) incidence, preoperative therapy-related outcomes (systemic chemotherapy, NACRT protocol completion rates, and treatment response), and surgery-related outcomes (waiting period for surgery, operative time, intraoperative blood loss, surgery-related AEs, and postoperative hospital stay).
Endoscopic retrograde cholangiopancreatography
All patients underwent endoscopic retrograde cholangiopancreatography (ERCP) after providing written informed consent. A side-viewing endoscope (JF-260V, TJF-260V, TJF-Q290V; Olympus Medical, Tokyo, Japan) was used during the procedure. Alternatively, in patients with surgically altered anatomy (except those undergoing Billroth I gastrectomy), a balloon-assisted enteroscope (EI-580BT; Fujifilm Medical, Tokyo, Japan) was used. Selective bile duct cannulation was performed using a standard ERCP catheter (MTW ERCP catheter; MTW Endoskopie, Wesel, Germany), with wire-guided cannulation and contrast medium injection. Subsequently, we performed cholangiography and measured the length of the bile duct stricture. During ERCP, we placed MH-SEMS at the biliary stricture. The length of the biliary stricture in the bile duct was measured to determine the stent length. In all patients, a 10-mm diameter MH-SEMS was placed with the distal end positioned below the papilla. No patient received rectal indomethacin during the periprocedural period.
Multi-hole self-expandable metallic stent
The MH-SEMS used in this study is a FC-SEMS with multiple side holes in the membrane (HANAROSTENTTM Biliary Multi-Hole NEO; M.I.Tech, Pyeongtaek, South Korea; Figure 2). The stent is made of nitinol wire and covered with a silicone membrane containing multiple small side holes (1.8 mm). The delivery system has a diameter of 8 Fr. In all patients, MH-SEMS with a diameter of 10 mm and lengths of 6, 7, or 8 cm were used. The 6-, 7-, and 8-cm stents contained 66, 78, and 90 holes, respectively, arranged in six evenly spaced rows around the stent.
Figure 2 Multi-hole self-expandable metallic stent.
Six rows of side holes were drilled on the membrane, aligning with the longitudinal direction of the stent (orange circles). Each side hole had a diameter of 1.8 mm.
Definition
Clinical and pathological staging as well as resectability were determined according to the Japan Pancreas Society Classification, 8th Edition (JPS 8th)[19]. The therapeutic effect was assessed according to the revised Response Evaluation Criteria in Solid Tumors (RECIST), version 1.1[20]. Diagnoses of cholangitis and cholecystitis were made based on the Tokyo Guidelines 2018[21]. Technical success, clinical success, and the severity of biliary drainage-related AEs, including RBO, were defined according to the Tokyo Criteria 2024[22]. AEs related to systemic chemotherapy and NACRT were defined in accordance with the Common Terminology Criteria for AE, version 5.0 (grade ≥ 3)[23]. In addition, surgery-related AEs were defined according to the Clavien-Dindo (CD) classification (≥ Grade IIIa)[24]. The pathological response to NACRT/TNT was assessed using the Evans classification[25].
RESULTS
Participant characteristics
Table 1 shows the clinical and demographic characteristics of the 14 participants. Clinical stages IIA, IIB, and III (JPS 8th) were identified in 11 (78.6%), 1 (7.1%), and 2 (14.3%) patients, respectively. Of the participants, 10 (71.4%) had R-PC, 2 (14.3%) had BR-PC, and 2 (14.3%) had UR-LAPC. Although we initially placed a PS in 7 of 10 patients with R-PC, the stent was quickly obstructed before the start of NACRT and replaced with an MH-SEMS. Of the remaining three patients with R-PC, initial biliary cannulation was difficult because of surgically altered anatomy in two patients and duodenal obstruction in one patient. Reintervention was expected to be difficult in these patients; thus, we initially performed MH-SEMS placement. Conversely, in four patients with BR-PC and UR-LAPC, MH-SEMS placement was selected as the initial drainage method because long-term TNT was planned prior to surgery (Figure 1). The median tumor size was relatively small (25 mm), with low rates of cystic duct invasion (21.4%) and main pancreatic duct involvement (50.0%). No patient underwent endoscopic sphincterotomy. All patients underwent NACRT as preoperative treatment, with gemcitabine plus intensity-modulated radiation therapy (IMRT; 54 Gy) as the regimen; this regimen was combined with S1 in one patient (7.1%). Systemic gemcitabine (1000 mg/m2) was administered weekly, and radiotherapy was delivered through 5-9 fields for a single course of 54 Gy in 27 fractions using an intensity-modulated radiation technique with a 6-megavoltage photon beam (Novalis Shaped Beam Surgery System, BRAINLAB). Within 3-5 weeks after NACRT completion, surgery was performed. However, four patients (28.4%) underwent systemic chemotherapy before NACRT as part of TNT.
Table 1 Participant characteristics, n (%)/median (range).
Participant characteristics
n = 14
Age (years)
70 (63-73)
Sex (male)
6 (42.9)
ECOG Performance status score
0
12 (85.7)
1
2 (14.3)
Surgically altered anatomy
Total gastrectomy (Roux-en Y reconstruction)
1 (7.1)
Distal gastrectomy (Billroth I reconstruction)
1 (7.1)
Intact gallbladder
13 (92.9)
Tumor size (during SEMS placement), mm, median (range)
25 (13-40)
Tumor location
Head
13 (92.9)
Body
1 (7.1)
Resectability
Resectable
10 (71.4)
Borderline resectable
2 (14.3)
Unresectable locally advanced
2 (14.3)
Clinical stage (JPS 8th)
IIA
11 (78.6)
IIB
1 (7.1)
III
2 (14.3)
Duodenal invasion
1 (7.1)
Tumor invasion to the cystic duct
3 (21.4)
Biliary stricture length (mm), median (range)
20 (9-40)
Maximum diameter of the common bile duct (mm), median (range)
13 (7-16)
Tumor involvement in the main pancreatic duct
7 (50.0)
Maximum diameter of the pancreatic duct (mm), median (range)
4.5 (2-10)
Laboratory data before the SEMS placement
Total bilirubin (mg/dL)
3.2 (0.9-7.3)
Aspartate aminotransferase (IU/L)
142 (53-581)
Alanine aminotransferase (IU/L)
271 (78-773)
Amylase (U/L)
53 (19-114)
Carcinoembryonic antigen (ng/mL)
5.4 (0.6-63.2)
Carbohydrate antigen 19-9 (U/mL)
134 (2-6711)
Duodenal pancreatic cancer antigen 2 (U/mL)
219 (25-1600)
Previous drainage
Plastic stent
7 (50.0)
None
7 (50.0)
Timing of MH-SEMS placement (including exchange from plastic stent)
Before starting systemic chemotherapy and NACRT
14 (100)
After starting systemic chemotherapy or NACRT
0
Cannulation methods
Catheter with contrast medium injection and guidewire
11 (78.6)
Pancreatic guidewire
3 (21.4)
Accidental contrast medium injection into the pancreatic duct
Table 2 shows the clinical outcomes and AEs. Clinical and technical success was achieved in all patients. All patients completed the radiotherapy protocol; however, one (7.1%) failed to complete the chemotherapy protocol because of a bone fracture. Based on imaging studies (RECIST) for preoperative treatment, partial response was noted in five (35.7%) patients. Tumor markers decreased significantly in most cases immediately before surgery following NAT. Although three (21.4%) patients developed post-ERCP pancreatitis (PEP) as an AE of MH-SEMS placement, none developed severe PEP, and all recovered with conservative treatment alone. No patients developed cholecystitis, nonocclusive cholangitis, liver abscess, or hemorrhage.
Table 2 Clinical outcomes and adverse events, n (%)/median (range).
Outcomes
n = 14
Technical success
14 (100)
Clinical success
14 (100)
Neoadjuvant chemoradiotherapy completion
13 (92.9)
Radiotherapy protocol completion
14 (100)
Chemotherapy protocol completion
13 (92.9)
Tumor size (after neoadjuvant chemoradiotherapy), mm
20 (5-30)
Therapeutic effects based on imaging studies (RECIST)
The median interval between stent placement and surgery was 105 days. One patient (7.1%) initially diagnosed with UR-LAPC developed moderate cholangitis because of sludge-induced RBO 337 days after stent placement during systemic chemotherapy. The obstructed stent was replaced with the same MH-SEMS model because no AEs occurred when MH-SEMS was first placed, and stent patency was maintained for a relatively long period. The patient’s condition improved after the MH-SEMS replacement. No stent migration was observed in any patient.
Surgical outcomes
Table 3 shows the surgical outcomes. All patients underwent pancreaticoduodenectomy, and five (35.7%) also underwent portal vein resection. The median intraoperative blood loss volume was 320 mL, with five patients (35.7%) requiring blood transfusions. The median operative time was 460 min. Postoperative complications included pancreatic fistula in one (7.1%) patient and superficial wound infection in three (21.4%) patients (≥ CD IIIa). No perioperative deaths occurred. Resection margins were free of tumor in all patients. In the final pathological response according to the Evans classification, one (7.1%) patient was classified as I, eight as IIa (57.1%), and five as IIb (35.7%). The final pathological stage based on JPS 8th was IA, IIA, and IIB in one (7.1%), six (42.9%), and seven (50.0%) patients, respectively.
Table 3 Clinical outcomes of the surgery, n (%)/median (range).
Outcomes
n = 14
Surgical procedures
Pancreatoduodenectomy
14 (100)
Combination with portal vein resection
5 (35.7)
Intraoperative characteristics
Blood loss (mL)
320 (107-1900)
Operative time (minute)
460 (249-714)
Intraoperative transfusion
5 (35.7)
Incidence rate of postoperative complication (≥ CD IIIa)
This study is the first to assess the feasibility of endoscopic biliary drainage using MH-SEMS during NACRT in patients with MDBO secondary to R/BR-PC. The incidence of RBO during NACRT/TNT was low, and the surgical outcomes were favorable. Although many patients in this study underwent aggressive preoperative treatments such as NACRT/TNT and tumor shrinkage was observed in postoperative pathological specimens, none experienced stent migration or cholecystitis. Although there were no severe cases in the cohort, the incidence of PEP was high.
No clear evidence exists regarding the efficacy of preoperative treatment for R-PC. However, in Japan, recent randomized controlled trials have shown that neoadjuvant chemotherapy with gemcitabine and S-1 prolongs survival in R-PC[1]. Therefore, the Japanese PC guidelines recommend NAT for R-PC to improve prognosis[2]. Recently, the concept of TNT has been proposed and indicated in BR-PC and selected UR-LAPC cases[7]. The widespread adoption of aggressive preoperative treatment has prompted discussion on the optimal preoperative biliary drainage methods. Considering the extended interval before surgery with such treatments, biliary stents require longer patency. The cost of preoperative biliary stents should also be considered; however, it remains unclear whether metal stents (MSs) or PSs are superior. Surgeons at our hospital reported that, although MSs are more expensive than PSs, MSs in patients undergoing preoperative NACRT demonstrate longer patency, lower reintervention rates, and no overall economic disadvantage[11]. Moreover, several studies have reported long patency of MH-SEMS in patients with MDBO[15-17], and its multi-hole design helps prevent stent migration. However, reports on the preoperative drainage of MH-SEMS remain limited. In a recent retrospective report, Takahashi et al[16] presented the outcomes of 111 cases of MH-SEMS placement, including 19 R-PC cases that underwent NAC. They reported that MH-SEMS had a good patency and low migration rate during the preoperative NAC period; however, perioperative complications and pathological assessments in resection cases were not adequately evaluated. In our study, all patients underwent NACRT; notably, some proceeded to surgery after an extended course of chemotherapy as part of TNT. Thus, we evaluated the efficacy of MH-SEMS during intensive preoperative treatment, along with surgical and pathological outcomes, highlighting the strength of the present study.
Preoperative biliary drainage should not adversely affect surgery or the pathological evaluation of surgical specimens. Although intraoperative bleeding or postoperative complications were observed in some of our patients, they were not associated with MH-SEMS placement or MH-SEMS-associated AEs such as PEP. Preoperative biliary SEMS must be removable to allow accurate pathological evaluation of surgical specimens. The MH-SEMS was successfully removed after surgery, and the specimens were evaluated without issue (Figure 3). This stent type has been shown to be endoscopically removable for up to 200 days after placement[15-17]. In the present study, RBO occurred 337 days after MH-SEMS placement in one patient, and the stent was easily removed endoscopically and replaced with a new MH-SEMS. Conversely, uncovered SEMSs or conventional partially covered SEMSs (PCSEMSs) may be nonremovable because the tissue becomes strongly embedded in the bare structure. Although FC-SEMSs can be removed, the stent may migrate. MH-SEMS is broadly classified as a PCSEMS; however, it is likely removable because the tissue is moderately embedded in the multi-hole structure, allowing removal during AEs if necessary.
Figure 3 Endoscopic findings and resected specimens.
A: The endoscopic image. A multi-hole self-expandable metallic stent (MH-SEMS) was inserted in a patient with malignant distal biliary obstruction caused by borderline resectable pancreatic cancer with portal vein invasion; B: The fluoroscopic image of MH-SEMS; C: After surgery (pancreatoduodenectomy with portal vein resection), the stent was easily removed from the surgical specimen. The yellow arrow points to the Papilla of Vater after stent removal; D: The resected specimen was diagnosed appropriately without being affected by stent removal. The yellow arrowheads denote the common bile duct after stent removal.
Safety is crucial for preoperative biliary drainage. In particular, cholecystitis is a serious AE associated with covered SEMS placement, potentially affecting preoperative therapy. In the present study, no patient developed cholecystitis. The multi-hole structure of MH-SEMS was expected to prevent cystic duct obstruction, thereby reducing the risk of cholecystitis. However, tumor invasion into the cystic duct may be a risk factor for cholecystitis development after covered SEMS placement[26-28]. The present study included relatively small-sized PCs, with a low incidence of cystic duct invasion. Therefore, it remains uncertain whether the absence of cholecystitis in all patients reflects the protective effect of MH-SEMS or the inclusion of a population at low risk for developing cholecystitis. Furthermore, PEP is a serious AE associated with covered SEMS placement. In this study, three patients developed PEP. The risks of PEP associated with covered SEMS placement include the main pancreatic duct without tumor involvement, intact papilla, placement across the papilla, and contrast injection into the pancreatic duct[28-31]. The present study included relatively small-sized PCs with limited main pancreatic duct involvement, which may have contributed to the higher incidence of PEP. Fortunately, PEP did not adversely affect preoperative treatment or surgery in our study. A combination of pancreatic stent placement and the use of a smaller-diameter MH-SEMS should be investigated to reduce the incidence of PEP after MH-SEMS placement.
Our study has several limitations. As a single-center, small case series, the generalizability of the results may be limited. Similarly, the effectiveness of MH-SEMS observed in this study may also be limited. A larger study comparing MH-SEMS with other SEMS may be necessary. Additionally, we examined the short-term postoperative outcomes; however, we could not observe the long-term outcomes. Thus, the effects of MH-SEMS on delayed AEs, such as postoperative liver abscesses and cholangitis, and survival rates remain unknown.
CONCLUSION
In conclusion, MH-SEMS is a potentially effective treatment option for biliary drainage in patients undergoing aggressive preoperative treatment including NACRT/TNT for PC because it is less likely to cause stent migration and has a low incidence of RBO. However, the incidence of PEP remains high; thus, future improvements, such as reducing the stent diameter, may be necessary.
ACKNOWLEDGEMENTS
We are grateful to the staff of our ward and endoscopy unit for their support in clinical management.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: Japan
Peer-review report’s classification
Scientific Quality: Grade A, Grade B, Grade D
Novelty: Grade B, Grade B, Grade D
Creativity or Innovation: Grade A, Grade B, Grade C
Scientific Significance: Grade A, Grade A, Grade D
P-Reviewer: Aboelhassan R, MD, PhD, Post Doctoral Researcher, Professor, Senior Researcher, Egypt; Reis Neves F, MD, Portugal S-Editor: Liu H L-Editor: A P-Editor: Zhao S
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