A variety of endoscopic techniques for the treatment of gastroesophageal reflux disease (GERD) have been developed as alternatives to PPI therapy or antireflux surgery. These techniques include submucosal suture plication of gastroesophageal junction (EndoCinch, ESD) or full thickness plication of the proximal fundic folds (Plicator, EsophyX, Syntheon ARD Plicator, Hiz-Wiz, MediGus SRS), the delivery of radiofrequency energy to the gastroesophageal junction (Stretta) and inject or implant biopolymers into the lower esophageal sphincter zone (Enteryx, Gatekeeper). Each of these endoscopic techniques is designed to augment the barrier function of the gastroesophageal junction. However, the underlying mechanism of action of the various endoscopic techniques has not been completely elucidated. Most studies have the improvement of symptoms and QOL, but poor improvement of pH monitor or manometric findings. Further, these therapies have only limited follow-up information, and safety issues remain unresolved.
Thus, endoscopic therapy for GERD is still evolving at this stage, and there are several newer devices under study or in development. Further studies with sham-controlled clinical trials to evaluate the subjective and objective outcome will be needed to determine the true role of endoscopic procedure for GERD.

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Endoscopic submucosal dissection (ESD) is becoming a common and useful treatment for superficial esophageal cancer, especially for tumors confined to the lamina propria mucosae which can be completely resected without any cancers fraction left. Here we report a case in which an SM infiltrated esophageal cancer resected by ESD, revealed a rapid and aggressive metastasis to a mediastinal lymph node (n106recR) before additional curative surgery. The possible existence of the lymph node metastasis could not be denied by retrospective re-assessment of CT which was performed before ESD. Although a relationship between the aggressive lymph node metastasis and the ESD procedure is unclear in this case, careful preoperative evaluation is necessary for the expansion of the indication of ESD for esophageal cancers.

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An 81-year-old woman, who underwent screening upper gastrointestinal endoscopy, was diagnosed with a 1.5-cm protruding esophageal lesion covered with normal epithelium (resembling the so-called 0-I sep type) located at 31 cm from the incisors. Biopsy revealed squamous cell carcinoma. The tumor depth was estimated to be m3-sm1 with a miniature probe. Endoscopic mucosal resection of the tumor was performed. Histologic examination of the resected specimen revealed thicking of the epithelium and infiltration of lymphocytes with lymphoid follicles into the mucosal lesion.

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A 66-year-old Japanese man visited at our hospital for close examination for gastric lesions. Endoscopic examination revealed a flat to mildly depressed lesion about 20mm in diameter at the anterior wall of the gastric angle. When the gastric wall was expanded weakly, the lesion was more visible as a flat depressed lesion than that was expanded strongly. Biopsy specimen revealed a differentiated adenocarcinoma. The lesion was resected en bloc by endoscopic submucosal dissection method. Histologically, resected specimen revealed a medullary carcinoma with lymphoid stroma. The lesion was limited to the mucosa and the margin was free of tumor cells. Then the patient received a distal gastrectomy in our hospital. In the resected surgical specimen, neither residual lesion nor metastatic lesion was detected. Endoscopic submucosal dissection method may be useful for diagnosis and treatment of these cases limited to the mucosa.

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A 38-year-old man was admitted to our hospital because of tarry stool and severe anemia. He had a history of massive anal bleeding 18 years ago. The bleeding source could not be detected either by gastroscopy or colonoscopy. Double-balloon enteroscopy revealed a 8 mm-diameter, hemispherical submucosal tumor with tension in the jejunum, 230 cm distal from the pylorus. We considered as this lesion responsible for bleeding, and resected partially. The pathological diagnosis of the submucosal tumor was arteriovenous malformation (AVM). Double-balloon enteroscopy is a useful modality for diagnosis and treatment of obscure gastrointestinal bleeding.

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A case of incomplete intussusception induced by appendiceal carcinoma is reported. A 58-year-old women presented with intermittent RLQ abdominal pain at a local hospital. Barium enema revealed a polypoid lesion and diverticula of the cecum, and she was referred to our hospital. On barium enema the absence of appendiceal filling, together with intramural filling defect on the medeal wall of the cecum, were indicating a cecal cancer or carcinoma of the appendix. Colonoscopy revealed the irregular subpedunculated tumor accompanied with a small nodule on the top of the tumor. The surface of the small nodule consisted of normal laying mucosa (the Volcano sign). Pathological examination of the biopsy specimens revealed group 5 from the tumor and group 1 from the small nodule respectively. We diagnosed the tumor to be the cecal cancer or carcinoma of the appendix, and right hemicolectomy was performed. One-thirds of the appendix invaginated into the base of the cecum, and the subpedunculated tumor measuring 47×30×40 mm was arising from the invaginated appendix. The surface of the invaginated appendix showed that the villous tumor had spread on it except for the small nodule on the top of the tumor. Because of a probe could pass through from the orifice on the small nodule to the tip of the appendix, we diagnosed the lesion to be incomplete appenciceal intussusception (Atkinson B-type). Histological examination of the surgical specimen revealed the proximal one-thirds of the appendix except for the top of the tumor was covered with papillary adenocarcinoma. Amount of the carcinoma was limited to the mucosal and submucosal layer, but small parts were invaded to muscularis propria. The lymphatic, venous involvement and lymphnodi metastasis were not detected. Intussusception induced by appendiceal carcinoma is very rare condition. It is the useful sign to diagnose of the appendiceal tumor with intussusception that the cecal filling defect with the absence of appendiceal filling on barium enema examination and the Volcano sign on colonoscopy.

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The patient is a 63-year-old female with systemic lupus erythematosus. Nearly two years previously, she had been treated with ecabet sodium and predonisolone enema for multiple rectal ulcers. She was admitted to our hospital with the worsening lower abdominal pain and rectal ulcers, and was treated with total parental nutrition. However, her symptoms got worse, and peritoneal irritation appeared. A CT scan showed diffuse edematous change of the intestinal wall not only in the rectum but also mainly in the small intestine. She was diagnosed with extensive lupus enteritis, and was treated with steroid and cyclophosphamide puls therapy. After the treatment, her multiple rectal ulcers and diffuse edematous change in the small intestine markedly improved with resolving abdominal pain.

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Colonoscopy was performed on a 55-years- old female for examination of sudden onset bloody mucus diarrhea. The colonoscopic finding revealed whitish capped polypoid lesions in the rectum. Histology of the polyps showed prominent fibrin exudates in the caps and inflammatory cell infiltration in the lamina propria. Cap polyposis was diagnosed from the above findings. After eradication therapy for Helicobacter pylori, both the symptoms and the colonoscopic findings of this patient almost disappeared. To date, there are only 12 cases reported on the eradication therapy for Helicobacter pylori to treat cap polyposis. Here, we report a case of cap polyposis which is successfully treated by the eradication of Helicobacter pylori.

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[Purpose]Narrow band imaging (NBI), combined with magnifying endoscopy, was analyzed for gastric IIa like lesions, defined as discolored, flat protruded lesions, either presented with typical features of gastric adenoma on endoscopy irrespective of biopsy results, or lesions classified as group III on biopsy. The fine mucosal structure and micro-vessels were assessed to determine whether it is possible to differentiate gastric adenoma from cancer, by NBI combined with magnifying endoscopy.
[Methods]Between April 2007 and June 2008, 26 gastric IIa like lesions were observed by using conventional as well as NBI-combined magnifying endoscopy. We evaluated the degree of disappearance of fine mucosal structural elements and microvascular abnormalities on NBI-combined magnifying endoscopy in these lesions. The lesion was classified based on these two findings. All the lesions were endoscopically resected en bloc and subject to pathological examination.
[Results]Pathological findings of the resected specimen suggested adenoma in 9 lesions and adenocarcinoma in 17 lesions. The lesions could be classified into 5 types based on the feature of NBI-combined magnifying endoscopy. 90% of the lesions that have endoscopically been dclassified as type-I or II according to our criteria were pathologically diagnosed as adenoma, while all the lesions classified as type-III, -IV, or V were pathologically diagnosed as adenocarcinoma.
[Conclusion]Endoscopic feature based on NBI-combined magnifying endoscopy was useful to differentiate adenomas from cancer in gastric discolored, flat protruded IIa like lesions.

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Endoscopic treatments for postoperative esophageal strictures can improve QOL of the patients simply and easily to make oral intake. However, excess dilatation may cause a grave complication such as perforation, when we perform surgical treatment occasionally. We need to understand appropriate stricture and endoscopic treatment.
Esophageal stricture is classified roughly into 2 of anastomotic stricture after esophagectomy and scarred stricture after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). As for the anastomotic stricture, there is much membranous stricture to be a cause of automatic anastomosis device, and, as for the stenosis after EMR or ESD, there is much scarred stricture to occur in a broad mucosal healing process with mucosa absence of higher than 3/4 laps. In dilation, there are two kinds of methods, to use a TTS balloon and a Savary-Gilliard dilator tube.
A balloon dilation expands balloon expansion by pressurizing to expand a narrow segment. We can perform endoscopic observation at expansion and from adaptation of expansion pressure being possible. So it is used as first choice of dilation for postoperative esophageal stricture and mainly used for membranous stricture. However it is in particular unsuitable for a case advanced firmly.
On the other hand, a Savary-Gilliard dilator tube dilation is used by guide wire under fluoroscope. The dilation is strong so that force reaches as well as short axes lie longitudinally is possible. For balloon dilatation unsuccessfulness example, it is particularly effective.
Endoscopic dilation for postoperative strictures can use possible in simple and easy if we take both methods adequately. However we perform carefully not to raise the risk to cause accident as for the excessive dilation and the blind maneuver.

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Background:Many experimental studies have shown the technical feasibility of natural orifice translumenal endoscopic surgery (NOTES). We report the first clinical application of natural orifice transgastric endoscopic peritoneoscopy in Japan for preoperative staging in a patient with pancreatic cancer.
Methods:A submucosal tunnel was created for safe peritoneal access and secure closure of the gastric-incision site.
Results:Transgastric peritoneoscopy provided an excellent view and allowed approoach to various areas of the abdominal cavity. After confirmation of operative curability, the patient underwent an open standard operation without complication.
Conclusions:Natural orifice transgastric endoscopic peritoneoscopy for cancer staging using the submucosal tunnel technique appears to be feasible and safe.

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