Endoscopic biliary stenting has been performed since 1979. The stent is two different materials of plastic (PS) and metallic (MS). The metallic stent has Uncovered or Covered The benign biliary stenosis is placed PS. The stent patency of Covered MS is longer than Uncovered MS and PS in the distal malignant biliary stenosis. Uncovered MS is longer than PS in the hilar malignant stenosis . We don't become clear that the bilateral hepatic duct drainage is better than unilateral drainage in the patient with malignant hilar biliary stenosis In the future, we will available to use a drug-eluting stent and inbiliary radiation therapy I strongly expect the new stent ; easy to insertion, long stent patency (over six months), easy to exchange and reasonable price.

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Wound bleeding post percutaneous endoscopic gastrostomy (PEG) is a known complication that occurs in the early stage post PEG. The present study determined whether wound bleeding could be prevented by not penetrating abdominal wall subcutaneous vessel, having identified them using light transmitted by the endoscope during skin incision. One hundred forty-four patients were divided in to three groups : the small PEG puncuture region incision (small incision) group (n=20) ; the large PEG puncture region incision (large incision) group (n=38) ; and the large incision that avoided transmitted vessels (large incision avoiding transmitted vessels) group (n=86). The frequency of wound bleeding and the frequency of peristomal wound infection were compared between 3 groups. In the small incision group, and the large incision avoiding transmitted vessels group, the frequency of wound bleeding was 0%, whereas the large incision group the frequency was 7.0%. In small incision group ; the peristomal wound infection rate was 10%, it was 2.3% the large incision group and 0% in the large incision avoiding transmitted vessels group. The identification of the subcutaneous blood vessel using the transmission illumination of the endoscope prevented wound bleeding, the transmitted vessels could kept away from the skin incision site.

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Most cases of DAVE (GAVE) are successfully treated with endoscopy, especially those requiring coagulation. A 65-year-old woman was referred to our hospital due to anemia . On upper GI endoscopy, DAVE and with liver cirrhosis caused by the hepatitis B virus were identified. Endoscopic treatment for hemostasis was done 14 times . However, the DAVE recurred frequently. The patient required blood transfusions and was readmitted several times .Therefore, a gastrectomy was done. However, an anastomotic gastric varices developed and ruptured 8 days after surgery. EVL combined with the aethoxysklerol (AS) fibrosing method was successfully used to deal with the varices. None of the previously reported GAVE case, that had surgery developed ruptured gastric varices in the early stage after gastrectomy . It must be kept in mind that a gastrectomy in a patient with portal hypertension, can result in ectopic varices. Four years after surgery, the patient is alive and has had no recurrences of GAVE or anastomotic varices.

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A 63-year-old man was admitted to a clinic because of vomiting and epigastic pain after eating bitter persimmons. Upper gastrointestinal endoscopy revealed a yellowish floating mass measuring 6cm in size. We diagnosed the mass as persimmon bezoar. We asked patient to drink Coca-Cola every day and performed a direct endoscopic dispersion of Coca-Cola using ERCP cannula. At repeated endoscopy, we could observe that the bezoar turned to be softened and finally disappeared. This form of dissolution of a persimmon bezoar proved to be rapidly effective, inexpensive, and safe in this case.

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Two patients, 79- and 60- year old males, underwent transanal prostate biopsy. After the procedure they developed severe melena. Emergent colonoscopy revealed spurting and pulsatile bleeding from the anterior rectal wall. Endoscopic clipping and endoscopic band ligation (EBL) were performed, which successfully attained hemostasis. Endoscopic hemostasis could be an effective treatment of choice for sever rectal bleeding after transanal prostate biopsy.

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A 53-year-old woman who refuses blood transfusion based upon her religious belief was referred to our institution. She had 40 mm of a laterally spreading tumor in the transverse colon. Under no sedation, colonoscopy was performed in the Endoscopy Unit . On both plain and magnification chromocolonoscopy, there were no findings suggesting a substantial invasion into the submucosal layer. Endoscopic mucosal resection was selected as an initial treatment . At the first cutting with snaring, spurting bleeding from the thin vessel occurred and then was successfully stopped by endoscopic clipping . Endoscopic resection was continued for the remaining lesion and finally the whole lesion was resected at piecemeal fashion . Absence of recurrent lesion was confirmed by repeat colonoscopies . This paper discussed therapeutic procedure and the management of a large colorectal tumor developing in the patients who refuses blood transfusion based upon their religious belief.

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Colocutaneous fistula is a rare complication of percutaneous endoscopic gastrostomy (PEG). We experienced three cases of colocutaneous fistula after PEG successfully managed without surgical revision. In two cases, colocutaneous fistula were discovered with no signs of peritonitis or obstruction at the time of the PEG tube exchange, three months and nine months after PEG, respectively. After the PEG tubes were removed with total parenteral nutrition and systemic antibiotics treatment for one week, the fistulae healed spontaneously. The former patient underwent repeat PEG with a care to avoid injury to the colon and the latter improved difficulty in swallowing by means of rehabilitation resulting in no need for PEG. In the last case, colocutaneous fistula became apparent at four days after PEG. Fluologram showed the tip of the PEG tube in the transverse colon and a gastrocolic fistula formation without peritoneal leakage. The PEG tube was removed one month after PEG, with total parenteral nutrition and systemic antibiotics treatment and PEG was performed again. In conclusion, conservative management of colocutaneous fistula after PEG is a safe and reliable option in cases without evidence of peritonitis.

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Background : Endoscopic submucosal dissection (ESD) to colorectal tumor has not been established widely. One reason is that perforation related with endoscopic therapy is shown more frequently because colorectal wall is thinner than gastric wall. Another reason is that peritonitis after perforation could be fatal because colon is more bacterial. In the current study, we analyzed cases with colorectal tumor performed ESD, especially cases with perforation due to ESD. We have evaluated ESD for colorectal tumor.Methods : Thirty one cases, which ESD to colorectal tumor had been performed from April, 2006 to June, 2007 at Nara City Hospital, were analyzed in the current study. We used Flex knife (Olympus, Tokyo, Japan) and Flush knife (FTS, Tokyo, Japan). Tumor size, operation time, and frequency of endoscopic perforation during ESD were examined. Also, abdominal computed tomography (CT) was performed routinely one day after ESD. Vital sign including fever elevation and abdominal findings were examined one day and two days after ESD. WBC and CRP in blood examination were calculated one day and two days after ESD.Results : Median tumor size was 26.8 mm in diameter (range : 10-60 mm). Median operation time was 85 minutes (range : 30-290 minutes). Histological diagnosis was 7 low grade adenomas, 6 high grade adenomas, and 18 cancers. The frequency of endoscopic perforation during ESD was 12.9%, 4 out of 31 cases. The reasons of perforation were that 2 were due to coagulation in muscle layer and one was due to snaring and one was due to clipping to ulceration due to ESD. The frequency of perforation detected by CT was 16.1%, 5 out of 31 cases. Abdominal pain was observed in only one case, which had endoscopic perforation. Clinical course of perforation was that all cases were cured only by endoscopic clipping without urgent surgical operation. In related with blood examinations, CRP elevated in cases with endoscopic perforation two days after ESD statistically.Conclusions : ESD to colorectal tumor was effective therapy to large tumor though perforation during ESD was observed more frequently than endoscopic mucosal resection (EMR). Endoscopic clipping could be performed to all cases because the hole of perforation was quite small. They could be cured without urgent surgical operation. Perforation has been still one of major problems for normalization of ESD to colorectal tumor. However, many of them could be cured by endoscopic therapy.

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Endoscopic ultrasound sonography (EUS) has been reported to be useful for the diagnosis of submucosal tumors (SMT) in upper gastrointestinal tract. But the diagnosis of SMTs and the evaluation of malignancy are difficult using by EUS alone, because SMTs include various kinds of diseases and various degree of malignancy. Therefore, Immunohistochemical staining for diagnosis of SMTs are necessary by acquiring the specimens, such as gastrointestinal stromal tumor (GIST). However, endscopic biopsy materials are not enough to make a different diagnose of SMT. EUS guided fine needle aspiration biopsy (EUS-FNA) developed in 1992, has been a useful technique for acquiring the specimens in the wall of the digestive tract . The rate of adequate specimens of SMTs may be somewhat lower than that of adequate specimens of pancreatic mass and lymph nodes. The technical tips of acquiring specimens of SMT using by EUS-FNA include selection of the needles, puncture site of lesions, change of negative pressure, and fixation the EUS scope by cooperator.

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Background : Gastric antral vascular ectasia (GAVE) is characterized by diffuse vasodilation mainly affecting the antrum and causes gastrointestinal hemorrhage. Argon plasma coagulation (APC) provides rapid coagulation of a wide region, and thus appears to be more useful than conventional methods for the treatment of extensive lesions with superficial oozing bleeding, such as GAVE. In this study, we evaluated the use of APC for GAVE.Methods : The study subjects were 22 patients with GAVE (10 men and 12 women, mean age 65.8 years, diffuse type [n=19] and watermelon type [n=3]) who developed gastrointestinal hemorrhage (melena, fall in hemoglobin [Hb, by ≤2.0 g/dl], or endoscopy-confirmed bleeding) and treated with APC. Endoscopic treatment was applied weekly, and considered successful if all detectable GAVE lesions were eradicated and the Hb stabilized without further transfusion. Clinical outcome was assessed.Results : The median total number of treatment sessions was 4 (range : 2-9 times), and the median observation period was 23.5 months. The cumulative recurrence-free rate was 49.7 after 1 year, 35.5% after 2 years, and 35.5% after 3 years. The survival rates after treatment were 94.4, 75.8 and 64.9% at 1, 2, and 3 years, respectively. No complications of APC were observed.Conclusion : APC appears to be effective for temporary control of hemorrhage and anemia due to GAVE, but is not always effective over the long-term. For proper management of GAVE, drug therapy, blood transfusion and control of the underlying disease are necessary in addition to achieving hemostasis temporarily by APC.

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