We analyzed 7 judicial precedents associated with digestive endoscopy sentenced between 2004 and 2006 in Japan, on the risk management point of view. Compared with judicial precedents sentenced before 2004, the number of cases related to endoscopy associated with the pancreas and the bile duct tract, such as ERCP and EST, has increased. In addition, one case was associated with endoscopic ultrasonography, which had not been detected before 2004. By this analysis, we can clarify the medical knowledge and skills that are required in staffs, and medical information and advise that should be given to patients legally, at present.

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We experienced fourteen cases of basaloid carcinoma and analyzed their endoscopic diagnoses, clinicopathological characteristics and results of treatment and the average age was 66 years old, only one was female. The locations of the tumor were ; nine cases of middle thoracic esophagus (Mt), three cases of lower thoracic esophagus (Lt), one case of cervical esophagus (Ce), and one case of abdominal esophagus (Ae). The tumor types were ; seven cases of a superficial type (0-I sep ; three cases, 0-I pl ; one case, 0-I p ; two case and 0-II a +II c ; one case ; all of them were of a protruding type), and seven cases of an advanced type (Type 1; two cases, Type 2; 1 case and Type 3 ; four cases). Histologic examination of biopsy specimens revealed well to poorly differentiated squamous cell carcinoma except for three advanced cases. Surgical resection was performed in twelve cases, and adjuvant chemotherapy was instituted in three cases and adjuvant radiotherapy in one case. Eight patients are alive without recurrence. A total of 89 cases of basaloid carcinoma reported in Japan, including our fourteen cases, were investigated clinicopathologically. The gross appearance of basaloid carcinoma commonly shows that of submucosal tumor and therefore preoperative diagnosis of the tumor is difficult to establish, culminating in a highly malignant potential due to its invasion into lymphatic and blood vessels. These days, long time survival has been reported in case of early-stage basaloid carcinoma. Investigation into histogenesis and growing pattern of basaloid carcinoma based on histopathological evidence, will therefore be helpful for better diagnosis and treatment of the tumor.

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45-year-old male was hospitalized due to gastric dyscomf ort. On gastrointestinal endoscopy, scattered erythematous lesions and ulcer were found in the stomach ; an erosion was seen in the duodenum. During his hospitalization, the patient developed lower abdominal pain. On colonoscopy, scattered erythematous lesions were found in the colon. On repeat colonoscopy, a purple lesion was noted. The patient was diagnosed as having Schonlein-Henoch purpura based on skin pathology findings. This case illustrates the unique gastrointestinal findings in Schoenlein-Henoch purpura.

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The patient was a 71-year-old woman who underwent hepatic arterial infusion chemotherapy using fluorouracil (5-FU) for recurrent liver metastasis of colon cancer. Abdominal CT showed pseudoaneurysm at the base of the gastroduodenal artery after 4 months. Further abdominal CT 11 months after starting 5-FU showed development of the pseudoaneurysm and dislocation of a catheter tip into the gastric antrum, but the patient remained asymptomatic, so no treatment was performed. Massive hematemesis occurred 14 months after starting 5-FU from pseudoaneurysm rupture into the duodenal bulb. Pseudoaneurysm underwent coil embolization, which stopped bleeding. Several days later, the catheter tip was removed using a 2-channel endoscope. Various complications related to intrahepatic arterial infusion chemotherapy have been reported, but the complications described here are rare and have not previously been reported. Since unexpected complications could occur, careful follow-up is warranted after hepatic arterial infusion chemotherapy.

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A 56-year-old female visited our hospital with positive indication of fecal occult blood. Endoscopy revealed a submucosal tumor, 10mm in diameter, in the lower rectum. Endoscopic ultrasonograpy revealed a low echoic lesion between the second and third layer, and strong echo area in the center of the lesion. We performed endoscopic mucosal resection for this lesion. Histrogical diagnosis was rectal carcinoid, and carcification was found in the center of the tumor. A case of gastrointestinal carcinoid with carcification is rare. We discussed and reported about rectal carcinoid with carcification.

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****Department of Diagnostic Pathology, Kyoto University Hospital. The 57-year-old male patient visited our hospital for the through examination of increased CA 19-9. He had presented no abdominal symptom or abnormal defecation so far. Colonoscopy showed segmental colitis and two elevated lesions ; type 0-II a at the ascending colon and type 0-Isp at the descending colon. We diagnosed this case as the high grade dysplasia and the colitic cancer associated with ulcerative colitis (remission state of the total colitis), and he underwent a total colectomy. Such a case with colitic cancer at the time of diagnosis of UC is very rare, and so we report it and considered about the high risk marker of the colitic cancer, including gene mutation.

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A 50-year-old man was admitted to our hospital with epigastric pain. Endoscopic examination showed a large submucosal tumor at the lesser curvature of the lower body of the stomach. Abdominal computed tomography demonstrated that the submucosal tumor had calcification. Endoscopic ultrasonography revealed a hypoechoic heterogeneous mass which mainly occupied the third and forth layer of the gastric wall. Aspiration cytodiagnosis was performed, but malignancy could not be ruled out. A subtotal gastrectomy was performed. Histological examination of the resected tumor revealed pancreatic tissue with neutrophil infiltration and calcification. We experienced a case of gastric aberrant pancreas with epigastric pain and pancreatolithiasis.

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With the increase of colon cancer, colonoscopy is getting demanded more. Insertion method of double balloon colonoscopy is explained in this technical review. Double balloon colonoscopy is an easy, safe and reliable method. In this method, the inserting force applied to the endoscope shaft is effectively transmitted to the endoscope tip while preventing the stretching of the colon with a balloon-attached overtube. Because the shape of the colon is arranged to be suitable for insertion by gripping the colon with the balloons, the endoscope can be inserted reliably with minimal pain. Double balloon colonoscopy enables total colonoscopy in difficult cases with regular colonoscopy. It is also useful for colonoscopic treatment because it can provide good control of endoscope tip. For acquiring the skill of insertion, it is important to understand the principle of the method and try to insert the endoscope as gentle as possible.

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Leiomyoma is a relatively common submucosal tumor in esophagus. The technique and efficacy of a novel method for the resection of these tumors, endoscopic enucleation using the jet of saline, was evaluated. Endoscopic ultrasonography (EUS) was always performed before the resection. If the high echoic layer was verified the outside of the tumor in the esophageal submucosal layer, this esophageal endoscopic enucleation was selected, but if the tumor was attached to the muscularis propria of the esophagus, thoracoscopic enucleation was recommended. The method of esophageal endoscopic enucleation was as following. The mucosal layer on the submucosal tumor was incised by a needle knife, the tumor was directly grasped with endoscopic forceps and dissected from the esophageal submucosal layer with the jet of saline by a hydro-dissection pump or a electric pressure pump. A week after resection, the lesions were observed endoscopically. Esophageal endoscopic enucleation was selected in 27 cases of leiomyoma arising in the submucosal layer as determined by EUS and successful in 25 cases. The size of the specimens was 1.8 cm (0.8-4.5 cm), and all of the resulting ulcerations at the site of resection healed without the fur within 1 week. The pneumomediastinum was occurred in only 1 case, and the complication rate resulting from this procedure was acceptable. There has been no local recurrence in completely sloughed cases. Conclusions : Our technique of endoscopic enucleation using the jet of saline appears to be a safe and useful procedure for esophageal submucosal leiomyomas.

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