A physician has an obligation to appropriately carry out diagnosis and treatment by effectively utilizing his medical knowledge and skills, and to have the awareness that medical codes of ethics as well as related laws and regulations constitute the code of conduct to which physicians must adhere to in the daily performance of diagnosis and treatment. Endoscopic treatment is invasive, and, as such, there is a legal requirement for medical services to apply greater attention than it is required for general diagnosis and treatment. Informed consent is particularly important. At the root, there is legal accountability, which requires specific explanations on the suitability of treatment, selection of the method of treatment, effectiveness of treatment, complications, among others. A healthcare provider who does not provide sufficient explanation will be held legally liable, and, if a complication or an accident occurs, even when sufficient explanations were given, a healthcare provider's legal liability would be judged based on whether or not the response was sufficient to meet a standard of medical service.
Medical audit in Japan is based on the methods used in the more advanced U.S. At present, however, the audit is performed mainly on the structure and process of medical services, and there is a need for audits on the more essential aspects of medical care, by using EBM-based clinical indicators in each field of specialization. For improvement in the quality of specialized medical services and for medical audit, clinical indicators on appropriate endoscopic examination and treatment need to be prepared. This should be considered through objective randomized controlled study. For preparation of clinical indicators for endoscopic treatment, it should be most appropriate for Japan Gastrointestinal Endoscopy Society (JGES) to fill the leadership role in conducting research and development.

View full abstract

We studied 1,731 patients who underwent endoscopic resection for colorectal adenoma and subsequent surveillance colonoscopy at least two times. A polyp was defined as an index lesion (IL) if it was larger than 10mm, has high-grade dysplasia or invasive cancer. The status where no neoplastic lesion more than 5mm in size was detected by surveillance colonoscopy was considered to be semi-clean colon. The cumulative hazard rate of IL before semi-clean colon exceeded 3% in 13 months after initial polypectomies. A risk factor of IL before the semi-clean colon status was achieved was the initial diagnosis of high grade dysplasia. The cumulative hazard rate of IL after the achievement of semi-clean colon exceeded 3% in 36 months after colonoscopies establishing semi-clean colon. Risk factors of IL after semi-clean colon were older patient age and the number of adenomas equal to or more than 3. We conclude that surveillance colonoscopy should be conducted annually until achieving the semi-clean colon status, and once every three years after establishing the semi-clean colon status.

View full abstract

A 57-year-old man was admitted to our hospital for further evaluation of the gastric tumor and submucosal tumor of the stomach. Upper gastrointestinal endoscopy showed depressed lesion on the anterior wall of the upper corpus and multiple submucosal tumor on the upper corpus to the antral part of the stomach. Biopsy specimens taken from the depressed lesion was diagnosed as gastric carcinoma. By using endoscopic ultrasonography, diffuse heterotopic gastric glands in submucosal layer were detected under the lesion of carcinoma. We conducted endoscopic submucosal dissection for the gastric carcinoma. The pathological diagnosis was well differentiated and papillary adenocarcinoma with submucosal heterotopic glands. Most of the carcinoma existed in gastric mucosal layer, but some of them invaded to submucosal layer (sm2). Furthermore, the carcinoma had multiple infiltrations to heterotopic gastric glands in submucosa. To reduce the risk of lymph node metastasis, total gastrectomy was performed. This is a rare case of early gastric carcinoma with multiple infiltrations to heterotopic gastric glands in submucosa.

View full abstract

A protruding SMT-like lesion measuring about 1 cm in diameter was found in the stomach of an 80-year-old male during a medical examination for liver cirrhosis. The lesion was covered with intact gastric mucosa, without any depression or erosion on the greater curvature of the antrum. The subsequent endoscopic observation of gastric mucosa at 6-month intervals could not find any change for 2 years. Thereafter, the top of the lesion demonstrated erosion. However, the impressive “double-humped” shape gradually appeared. Finally, the biopsy specimens taken from the erosion suggested gastric adenocarcinoma. A laparoscopy-assisted distal gastrectomy with D2 lymph node dissection was performed. The surgically resected specimens demonstrated a tumor consisting of moderately differentiated tubular adenocarcinoma with lymphocytic infiltration, mainly occupying the submucosal layer, and partially invading the muscularis propria and mucosal layer. However, there were no remnant cancer cells at the resected margins. Although such a small SMT-like gastric carcinoma is usually difficult to diagnose early, careful periodic endoscopic follow-up and attention to its morphological changes may be helpful for establishing a definitive diagnosis at an early stage.

View full abstract

A 71-year-old man with sigmoid volvulus underwent endoscopic reduction. The next day's X-ray revealed a niveau sign corresponding with recurrence of sigmoid volvulus. Re-treatment with endoscopic reduction and endoscopic insertion of a decompression tube per anum was performed, achieving a complete remission of the condition. This method might be useful in patients with sigmoid volvulus to present a recurrence after endoscopic reduction.

View full abstract

A 69-year-old female was admitted due to bloody stool in August, 2005. Colonoscopic examination showed the lesions like a blood blisters, and were surrounded by vascular ectasia. On pathology immunoglobulin light chain amyloidosis (AL) was diagnosed. She was treated for amyloidosis, but 7 months later, she again developed abdominal pain and had bloody stool. Colonoscopic examination showed ischemic colitis with a broad ulcerative lesion and mucosal abrasion in the sigmoid colon. On pathology amyloid deposits were noted in the wall of a submucosal vessel. The amyloid deposits were localized in the large intestine. This patient likely had localized primary AL-type amyloidosis. The patient's symptoms quickly improved with intravenous hypernutrition.

View full abstract

A 66-years-old-woman with abdominal pain was admitted. We diagnosed it as severe acute pancreatitis from findings of CT Grade IV. Pneumoretroperitoneum was recognized on the tertiary disease day and progressed gradually. On the 18^th disease day, we punctuated it, and pus was absorbed. Percutaneous abscess drainage was performed. Because the amylase value in pus was high, we suspected that pancreatic duct was disrupted and confirmed it on ERCP. ENPD was placed and abscess drainage reduced immediately afterwards. This case suggests that ERCP may be useful for controlling a pancreatic abscess after severe acute pancreatitis.

View full abstract

The systemic administration of a cholinergic blocking agent or glucagon reduces gastrointestinal spasm. However, using these agents is inconvenient and can sometimes causes side effects. Peppermint oil could replace these agents since it has an antispasmodic effect. Therefore, the present determined whether peppermint oil is a useful antispasmodic agent during transnasal esophagogastroduodenoscopy. Eight healthy volunteers were prospectively enrolled in this study. 20 ml of peppermint oil solution was administered in the antrum of the stomach, subsequently, number the times of spasms was noted. It was found that post peppermint oil solution treatment the number of antral spasms significantly reduced. The number of spasums was found to decrease one minute after the administration and the decrease lasted for 3 minutes. Thus, based in these results peppermint oil is a useful for antispasmodic agent in patients requiring transnasal esophagogastroduodenoscopy.

View full abstract

Balloon endoscopy (BES) have enabled an endoscopic approach to entire small bowel. Recently, the single balloon endoscopy (SBE) has been released. In this system, a balloon is attached to the only splinting tube, but not to the scope itself. The SBE is inserted as ; first, insert the scope deeply and grasp the intestine by angulating the bending section. Then, deflate the balloon on the distal end of the splinting tube, advance the splinting tube, and inflate the balloon. Then, withdraw both the scope and the splinting tube while releasing the angulation to shorten the gut. Repeat these steps. We are able to perform SBE using the one-person insertion method. In this procedure, hold the scope's control section with the left hand, and hold the scope and splinting tube with the right hand. Insert the scope by manipulating it with the right hand. The splinting tube has a tab so that the tube can be easily held and inserted. With each stroke, 0.3% crystal violet staining is used to mark the point that had been reached. This staining is helpful for marking. Carbon dioxide insufflation instead of room air is helpful for better insertion length and avoiding abdominal distention. Even one-way entire enteroscopy by retrograde insertion is possible in some cases. The SBE is useful for the diagnosis and endoscopic treatment for small bowel diseases.

View full abstract

Background:Placement of self-expandable metallic stents has become the preferred palliative treatment for patients with unresectable malignant biliary obstruction. Metallic stents provide longer patency compared with plastic stents. Distal malposition or migration of metallic stents sometimes occurs, but it is often difficult to remove them. We evaluated the efficacy and safety of argon plasma coagulation (APC), and the optimum conditions for cutting metallic stents (Wallstent).
Methods:We wrapped porcine small intestines around a metallic Wallstent with and without silicon lining membrane (Permulume^®), leaving the distal portion unwrapped to resemble the protrusion of the biliary metallic stent from the ampulla of Vater. APC irradiation was applied to the metallic stent at 1 cm from the edge of the wrapped small intestine at 30, 60 and 99 watts (W) for 3 or 6 s.
Results:Metallic Wallstent with the silicone-based membrane Permalume^® was cut at 30 W power, whereas more than 60 W power was required to cut the bare metallic wire. The irradiation of APC (flow rate at 2.0 L/min) at 30 W to the covered metallic stent transected the metallic mesh stent not only under dry but also under wet conditions (moisturized stent). Irradiation of APC caused no gross damage to the small intestines irrespective of the power applied and duration of irradiation.
Conclusions:Our results suggest that APC is efficacious and safe for endoscopic sectioning of wire mesh stents at low power (30 W) without gross damage to the surrounding pancreaticobiliary tissues.

View full abstract