In the early animal experimental stage when the new concept of NOTES (Natural Orifice Translumenal Endoscopic Surgery) appeared, fierce competition occurred in device development, but now, in the clinical application stage, we face various problems. To ensure safe clinical use, hybrid NOTES was devised. On the other hand, a trend for more minimally invasive rigid endoscopic surgery, such as single-port surgery, is spreading, which takes advantage of the characteristics of NOTES. Since technologies have been developed which bridge the gap with NOTES, such as closure of iatrogenic gastrointestinal perforation, endoscopic full-thickness resection, cellular and molecular imaging of the muscularis propria in the submucosa and peroral endoscopic myotomy, minimally invasive surgery and development of peripheral devices, triggered by NOTES, are considered to have led to new developments not only in the field of surgery, but also in the field of internal medicine. Closer cooperation between physicians and surgeons is important to further advance the common dream of more minimally invasive surgery, without adhering to the word and concept of “NOTES.” To keep up with Europe and the US in this field, it would be desirable to establish strong research systems in Japan by promoting industry-university-government cooperative research and close cooperation between medicine and engineering.

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The purpose of this prospective study was to investigate the safety of and the tolerance to oral sedation with midazolam for upper gastrointestinal endoscopy. In this study, 86 adult patients were randomized to receive oral sedation with 10 mg of midazolam (n=43) or intravenous sedation with 10 mg of diazepam (n=43). There was no statistically significant difference in base line characteristics between both groups regarding age, gender and body mass index. Of the respiratory and hemodynamic factors, blood pressure, pulse, oxygen saturation (SaO2), respiratory rate, end-tidal carbon dioxide (EtCO2) were recorded before drug administration (baseline) and then every 3 minutes until the end of the endoscopic procedure. No major respiratory depression was observed in either group, but hypoxemia (SaO2 < 90%) was found in every case. Blood pressure significantly decreased in the midazolam group, but only 1 case with hypotension under 90 mmHg was noted in the midazolam group and 5 cases in the diazepam group. Patient clinical responses (reflexes, extent sedation, overall tolerance and amnesia during the endoscopic procedure) were assessed on scales in all patients. In the midazolam group, complete amnesia was achieved in 67.4% of the patients and the mean amnesia score was significantly higher than the diazepam group. There were no statistically significant differences between groups in other score results. The majority of patients (83.7%) in midazolam group were willing to repeat the oral sedation for the next procedure, if necessary. The median recovery time was significantly longer in the midazolam group compared with diazepam group (56.3 min vs. 44.6 min).The results of this study indicate that oral administration of midazolam, which is a simple and convenient method, has the potential to be a safe and effective premedication for upper gastrointestinal endoscopy in adults.

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A 52-year old male was admitted for examination of an esophageal elevated lesion found during a screening endoscopy. X-ray examination revealed a round radiolucent lesion with an adjacent barium deposit in the lower thoracic esophagus. Endoscopy showed a slightly elevated lesion with a smooth surface, with an erosive lesion adjacent to the elevated one. Pathological diagnosis by endoscopic biopsy was squamous cell carcinoma. Endoscopic ultrasonography showed a hypoechoic lesion limited to the mucosal layer. CT and PET-CT revealed no metastatic lesions. Endoscopic submucosal dissection (ESD) was performed. The resected specimen showed a 1 cm slightly elevated lesion with a smooth surface and irregular shaped erosion on the anal side. Pathological examination revealed solid proliferation of basaloid cells which contained hyperchromatic nuclei and scanty cytoplasm. The tumor was mostly located in the lamina propria and had slightly invaded the submucosal layer (T1b-SM1). PAS positive deposits were observed in or between the tumor nests. Thus the diagnosis was basaloid squamous carcinoma of the esophagus. Basaloid squamous carcinoma of the esophagus has been reported to have a poor prognosis ; however, patients in the early stage have less lymph node metastasis. To improve the prognosis and to preserve the quality of life, early detection is important.

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We report herein on a case of a 67-year-old man with gastric metastasis from sigmoid colon cancer. Sigmoidectomy was performed for cancer in March 2005 following which the patient's CA 19-9 level was normalized. His CA 19-9 levels elevated again 27 months after the operation. An enlarged splenic lymph node and gastric tumor were diagnosed on MRI. Upper gastrointestinal endoscopy revealed a solitary submucosal tumor in the fornix of the stomach. Total gastrectomy and splenectomy were performed. Histological findings showed a well differentiated adenocarcinoma in the submucosal tumor. Immunohistochemical studies revealed positive staining for CA 19-9. These findings were similar to those of the patient's primary sigmoid colon cancer and therefore metastasis was diagnosed.

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A 53-year-old man visited at our hospital for examination of intermittent upper gastrointestinal bleeding and severe anemia which has persisted for five years. He had started hemodialysis for chronic renal failure 11 years previously. Upper GI endoscopy showed multiple longitudinal stripes of red vessels radiating in a spoke-like fashion from the pylorus to the antrum. We diagnosed this as gastric antral vascular ectasia (GAVE) and considered it was the cause of the bleeding. Argon plasma coagulation (APC) was performed but the patient was repeatedly transfused for intermittent tarry stools due to recurrence of the GAVE. We performed endoscopic submucosal dissection (ESD) of about one third of the GAVE lesion having received informed consent. The maximum size of the resected specimen was 60 mm. The histopathological findings were consistent with previous reports on GAVE ; dilatation of mucosal capillaries, fibromuscular hyperplasia of the lamina propria and vascular dilatation in the submucosa. The patient was asymptomatic and doing well 10 months after the ESD procedure. Endoscopic follow-up examinations showed no recurrence of GAVE in the area of the resection. We considered this case was important because it was to our knowledge the first instance of recurrent GAVE treated with ESD.

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A 67-year-old man visited a clinic with melena and was found to have a tumor, 25 mm in size, at the upper rectum. The patient was referred to our hospital for further examination and treatment. Colonoscopy showed a lobulated and pedunculated lesion with some ulcerations on the surface. The margin of the tumor was covered with normal mucosa. Although an early rectal cancer was suspected by the colonoscopic findings, biopsy results revealed a rectal carcinoid. We performed a laparoscopy-assisted low anterior resection for the tumor. A small rectal carcinoid typically presents as a hemispherical submucosal tumor covered with a yellowish and smooth surface. However, as a carcinoid tumor grows up to be greater than 20 mm in size, it may take the form of a pedunculated tumor frequently with a central depression or ulceration. In such cases, endoscopic differentiation from carcinoma may be difficult. Since a carcinoid tumor with such atypical macroscopic features has a high malignant potential, it should be clinically treated as a carcinoma.

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A 62-year-old man visited a nearby hospital with occult blood in his stool. Colonoscopy revealed a laterally spreading tumor (so-called LST) of the ascending colon measuring about 3 cm. The patient was referred to our hospital for endoscopic treatment. The endoscopic findings were a scarred area with discoloration on the cecum and ascending colon, and we diagnosed intestinal tuberculosis. The LST was found on the scarred area of the lower ascending colon. Magnifying colonoscopy revealed the type IIIL pit pattern of the tumor, which was treated with endoscopic submucosal dissection (ESD) and snaring. Histological examination of the resected specimen revealed carcinoma with high grade dysplasia, which was confirmed with haematoxylin and eosin (HE) and p53 staining. We report herein on a rare case of early colonic cancer associated with a dysplasia-carcinoma sequence of colonic tuberculosis like UC.

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We report on a case of colonic varices treated with multi-hemoclipping which is our new original endoscopic technique. A-76 year old female was diagnosed with Stage IVa pancreatic cancer according to the TNM classification two years ago. We performed gemcitabine (GEM) chemotherapy, but 20 months later, this patient was admitted to our hospital with massive lower gastrointestinal bleeding. Colonoscopy revealed a markedly dilated tortuous vein with an ulcerated section in the ascending colon. Via a colonoscopy the placement of 22 hemoclips strangulated these varices and also closed the variceal rupture. After treatment, the patient had no symptom of hemorrhage for two months during existence. This endoscopic multi-hemoclipping is possibly one of the effective treatments of colonic varices for both inoperable cases and those with variceal rupture.

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A 72-year-old male patient developed bile peritonitis after removal of a percutaneous transhepatic gallbladder drainage (PTGBD) tube for acute cholecystitis. He refused cholecystectomy, unfortunately conservative medical management proved ineffective. Immediately after endoscopic naso-gallbladder drainage (ENGBD) was performed, he improved completely. ENGBD may be useful for managing bile peritonitis following PTGBD.

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In Japan, there are no reports on any clinical case treated with a self-expandable plastic stent (SEPS). We have used the shortest Polyflex SEPS 20 mm in diameter and 50 mm in length, for refractory esophageal benign strictures. The SEPS was easily and safely placed and removed from the esophagus 7 months after stenting. SEPS is one of the promising options for the treatment of benign refractory esophageal strictures.

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Endotherapy has become widely accepted as an initial intervention for the treatment of chronic pancreatitis. Pancreatic sphincterotomy or balloon dilation of the pancreatic orifice allows access to the pancreatic duct. Endoscopic biliary interventions of stenting, dilatation, and stone extraction with or without extracorporeal shockwave lithotripsy have been applied to the pancreatic duct. Moreover, transluminal drainage of pancreatic pseudocysts has been enabled with the development of the echo-endoscope. However, failures of or complications with pancreatic interventions can be fatal. Selection of the appropriate intervention for each condition, acquirement of the technique, and knowledge of the characteristics of the devices are very important for the endoscopic management of patients with chronic pancreatitis.

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We herein explain the technique of transpapillary gallbladder drainage. The pattern of bifurcation of the cystic duct is mainly divided into 3 types : 1, right cranial type ; 2, right caudal type ; and 3, left type. We should perform transpapillary gallbladder drainage using the appropriate accessories according to the type being operated on. In particular, in the case of the right caudal type, a flexible tip catheter or papillotome should be employed. A Radifocus^® guidewire is useful for identifying bifurcation of the cystic duct using the techniques of rotation and looping of the tip. The Radifocus^® guidewire should be replaced with a stiff type guidewire for stable procedures. Finally, a pig tailed naso-gallbladder catheter (5-6 Fr) or a double pig tailed plastic stent (5-7 Fr) is placed.

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Objectives : Recently, the preference of women patients to deal with women doctors has been shown in various areas of medicine, for example genital examinations and issues about gender. We carried out a questionnaire-based investigation to see whether women patients preferred to undergo colonoscopies performed by female endoscopists. Methods : A total of 110 women patients who had undergone colonoscopies were asked about their gender preference regarding the examining physician before and after the examination. Results : The percentage of women patients who preferred women colonoscopists increased to 67% after colonoscopy, compared with 56% before colonoscopy. Seventy-two percent of younger patients (under 50 years) preferred female doctors, compared with 45% of older patients (over 50 years) (p=0.0044). Seventy percent of patients who had never undergone a colonoscopy preferred female doctors compared with 43% of patients who had experienced a colonoscopy (p=0.0047). Employed and asymptomatic patients showed a tendency to prefer female endoscopists compared with unemployed and symptomatic patients. Conclusions : We showed that women patients preferred to have colonoscopies performed by female endoscopists.

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