Pancreaticobiliary maljunction (PBM) is a congenital anomaly defined as a junction of the pancreatic and bile ducts located outside the duodenal wall, usually forming a markedly long common channel. Since the action of the sphincter of Oddi does not functionally affect the junction in PBM patients, continuous pancreatobiliary reflux occurs, resulting in a high incidence of carcinoma in the biliary tract. The treatment of choice for PBM is prophylactic surgery before malignant changes can take place. Diagnosis of PBM with endoscopic retrograde cholangiopancreatography (ERCP) is made when the communication between the pancreatic and bile ducts is maintained even during contraction of the sphincter. Characteristic pancreatographic findings of PBM are as follows : a dilated long common channel, duct derived from a common channel, dominant Santorini's duct, and frequent association with incomplete pancreas divisum. Endoscopic ultrasonography (EUS) and intraductal ultrasonography (IDUS) can demonstrate junction of the pancreatic and bile ducts outside the duodenal wall, and are useful to diagnose associated biliary carcinoma. Some cases with a relatively long common channel that are not classified as PBM because the sphincter of Oddi includes the pancreaticobiliary ductal junction (high confluence of pancreaticobiliary ducts) show pathophysiological changes similar to PBM.

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Background : Colorectal cancers with submucosal invasion (SM cancer) which have been endoscopically resected may need additional surgical therapy according to the depth to which the submucosa has been invaded. In the current study, we classified SM cancer into three groups based on the state of the muscularis mucosae (MM) and evaluated characteristics of each group. Methods : One hundred and fifty-eight SM cancers, for which endoscopic or surgical treatment had been performed from 1990 to 2005 at Kyoto Prefectural University of Medicine, were analyzed. According to the Japanese definition, we classified SM cancer into three groups by the state of the MM, i.e., the clearly identified group, identified group and unidentified group. We analyzed the characteristics of each group including the depth of submucosal invasion from the MM. Results : The median depth of submucosal invasion was 512 μm (range, 80-1250 μm) in the clearly identified group, 1504 μm (500-3710 μm) in the identified group and 4468 μm (1000-11000 μm) in the unidentified group. The positive rates of risk factors of lymph node metastasis in the clearly identified, identified and unidentified groups were 13.7%, 80% and 100%, respectively. Conclusion : The depth of invasion in all of the unidentified group cases was greater than 1000 μm. Thus, in all cases in this group, additional surgical resection was indicated. It is unnecessary to measure the submucosal invasion depth in the group of SM cancers with unidentified MM is not identified in the resected specimens.

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We have few opportunities to observe patients with of laryngeal tuberculosis, because this disease only exists in less than 1% exist in all of pulmonary tuberculosis patients. However, laryngeal tuberculosis is important as a differential diagnosis with a superficial cancer. Currently the diagnosis of this rare condition will probably increase, as we have the opportunity when performing upper gastrointestinal endoscopy (UGS) to screen the pharyngeal and a laryngeal region at the same time. This case report concerns a laryngeal tuberculosis patient in whom a superficial laryngeal cancer was first suspected under a high-magnification endoscopic diagnosis. The patient was a man in his 50's with pharyngalgia. The doctor whom the patient consulted first discovered a superficial lesion in the epiglottis with a laryngeal fiberoscopy, and referred the patient to our hospital as having a suspicious malignant tumor. UGS findings revealed an obscure lesion which was reddish with white coat in the laryngeal side of the epiglottis. High-magnification endoscopy with narrow band imaging showed an atypical vessel pattern and granulated structure, the so-called frog spawn, without a normal vessel pattern. The finding was enough to remind us of malignant lesions. The histopathological findings from the biopsy, on the other hand, revealed only granulomatous changes with inflammatory cell infiltration and no neoplastic changes, and an acid-fast bacillus was discovered with Ziehl-Neelsen staining. The chest X-ray findings showed an infiltrative shadow with cavitation at both the superior lobe and apex of the lung. As a result, the patient was diagnosed as having pulmonary tuberculosis and secondary laryngeal tuberculosis. He underwent treatment with a combination of four antimicrobial agents in another hospital. We should diagnose laryngeal tuberculosis as soon as possible and prevent the spread of infection in the endoscopic unit, because of the high potential for infection. However, even UGS specialists might not be on top of this diagnosis because there is little experience of it. We should take the presence of laryngeal tuberculosis into consideration as a differential diagnosis of cancer, and confirm a diagnosis as soon as possible with whole body examinations including chest X-rays and bacteriological examinations.

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The patient was a 57-year-old male. Upper gastrointestinal endoscopy revealed an irregular erosion adjacent to a reddish area on the left side wall of the cervical esophagus. Biopsy specimens histologically indicated esophageal adenocarcinoma arising from the heterotopic gastric mucosa, and a subtotal esophagectomy was performed. Immunohistochemical examinations for MUC5AC, MUC6, MUC2, and Cdx2 were performed, the cancerous lesion was positive for MUC5AC, MUC6, MUC2, and Cdx2, and the background mucosa (heterotopic gastric mucosa) was positive for MUC5AC, MUC6 and Cdx2. Thus, this tumor was considered to be derived from the heterotopic gastric mucosa, with intestinal metaplasia. The case of cervical esophageal adenocarcinoma arising from the heterotopic gastric mucosa is very rare, and to our knowledge only 18 cases including our case have been reported in Japan.

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A 60-year-old man was admitted to the hospital for endoscopic submucosal dissection (ESD) for early gastric cancer. An intraoperative perforation occurred during the submucosal dissection using an IT knife 2 to resect the gastric lesion located on the posterior wall of the cardia. The perforation site was closed with clips, and the treatment was continued. About two hours after perforation, during treatment, the electrocardiogram showed marked ST depression with negative T wave in leads of II, III, aVF, V1∼V6. We performed an emergency cardioangiography under the suspicion of acute myocardial infarction. No significant stenosis in the coronary artery was revealed, but a left ventriculography showed left ventricular motion abnormality with hypokinesis of the base and hyperkinesis of the apex. We, therefore, diagnosed inverted Tako-tsubo cardiomyopathy. In this case, we thought that this type of cardiomyopathy was caused by the excessive invasive stress such as a pneumoperitoneum following perforation and the prolonged treatment. It is necessary to take this entity into consideration as a potential complication when performing ESD.

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A 62-year-old female was diagnosed as having a well-differentiated adenocarcinoma of the main papilla. Endoscopic ultrasonography showed that the tumor was limited to the mucosa of the duodenum. Abdominal ultrasonography and CT findings showed no evidence of lymph node swelling or metastasis (clinical stage T1). The patient gave informed consent for endoscopic snare excision. On histological findings of the resected specimen, a well-differentiated adenocarcinoma limited to the oral protrusion of the main papilla, (size 5 mm, m, ly0, v0, cut end (-), final stage pT1) was diagnosed. One year and two months after the endoscopic snare excision, no evidence of recurrence has been noted.

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A 57-year-old man was admitted to our hospital for lower abdominal pain. Colonoscopic examination revealed perforation of the sigmoid colon by a toothpick, which was successfully removed during colonoscopy. When peritonitis persists locally, colonoscopic removal could be one therapeutic option in cases of toothpick perforation. In addition, our experimental study indicates that the appearance of a toothpick in the body on CT images can be highly variable, which and that must be given sufficient consideration when we try to find a toothpick on CT images.

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We report on a case of a splenic abscess that penetrated to the stomach. A 43-year-old man was admitted to our hospital. He was suffering from fever, left flank pain, left hypochondric pain and left back pain. He was diagnosed as having a splenic abscess based on ultrasonography and computed tomography scans. Subsequently, penetration of the splenic abscess to the stomach was observed with upper gastrointestinal endoscopy. The patient was treated with antibiotics, and endoscopic drainage was performed with the endoscopic nasobiliary drainage (ENBD) technique. After the treatment, the drainage tube was removed, and the patient was discharged. Endoscopic drainage enabled the culture of the drainage fluid, and this was a safe and effective treatment. The splenic abscess is a relatively rare entity. This is the first case in the literature in Japan where an endoscopic examination revealed a splenic abscess with penetration to the stomach.

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Although widely used, insertion of a long intestinal tube for bowel obstruction is sometimes difficult, resulting in long procedure time and severe patient distress. Recently, there have been some reports on the use of transnasal ultrathin endoscopy for placement of a long tube, allowing for a shorter procedure time, decreased exposure to X-ray radiation, and less patient distress compared with direct insertion of the tube. A favorable technical success rate and safety equivalent to that of conventional insertion have also been shown. Endoscopy-assisted long-tube insertion is expected to become widespread as a safe and useful technique.

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