When talking about the evolution of the digestive endoscope, the electronic endoscope took the place of the fiberscope. As for endoscopic imaging, digital imaging took the place of film images. Digital images have some superior points compared to film images, such as resolution, modification, analysis, transmission and filing. However, various problems have cropped up during the era of digital imaging in digestive endoscopy. For example, we have to admit that less attention is paid to the endoscopic findings during endoscopic examinations, and a decreased need has appeared as regards the detailed observation of the endoscopic findings. The latter is caused not only by the direct pasting of the digital endoscopic image to the endoscopic report sheet without any sketch of the lesion, but also by use of MST (Minimal Standard Terminology). Owing to these problems, the ability of the endoscopist to make a diagnosis based on the endoscopic findings is continuously decreasing. Additional problems are the difficulty of utilizing the diversifying digital images, the easiness of digital image forgery and the easiness of digital image with patient's informations leakage to the outside of hospital. We should always pay attention to these serious consequences and make an effort to establish a full-dress training system and develop a forgery detection system for endoscopic digital images.

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Background : Squamous cell carcinoma of the oro-/hypo-pharynx (SCCP) is easily treated with endoscopic or endoscope-guided mucosectomy if detected at an early superficial stage with endoscopic screening. However, superficial SCCP is often overlooked because of the anatomical structures of the pharynx that create blind spots during regular endoscopic procedures. Thus it is important to develop procedures for widening and improving the endoscopic field of view of the pharynx for early precise detection of pharyngeal SCC.
Methods : The subjects consisted of 599 Japanese alcoholic men (≥^*40 years) who consecutively underwent cancer screening that used endoscopy combined with oropharyngolaryngeal inspection and esophageal iodine staining. We applied procedures for wide visualization of pharynx to the patients. First, after endoscopic inspection of the oral cavity, the patients were asked to bow their head deeply in the left lateral position, and then we put our hand on back of patient's head and pushed it forward by one span of our hand (approximately 20 cm). Then they were asked to lift up the chin as far as possible with the occipital point fixed by our thumb (lateral sniffing position). When inspecting the hypopharynx we asked them to say "E" and to hold their breath at full inspiration (Valsalva's maneuver). The extent of the view of hypopharyngeal opening was classified into 4 categories (very good, good, fairly good, and poor).
Results : The wide endoscopic view of the pharynx was obtained in a series of the procedures (very good, 58% ; good, 18% ; fairly good, 19% ; and poor, 5%). Oral or pharyngeal SCC was detected in 8 patients (3 hypopharyngeal SCC ; 2 oropharyngeal ; 1 oropharyngeal and hypopharyngeal ; 1 tongue and hypopharyngeal ; and 1 oral floor). All the lesions were the flat or slightly elevated type. Hypopharyngeal SCCs had invaded up to the subepithelial layer in 4 patients, and all the other SCCs were intraepithelial SCCs. All the SCCPs were detected in those patients whose extent of hypopharyngeal opening was determined to be very good (4/7) or good (3/7). Esophageal SCCs were detected in 19 patients, and the SCCs were intraepithelial cancer in 10 patients, had invaded up to the proper mucosal layer in 3 and up to the submucosa in 3, and into proper muscular layer or deeper in 3.
Conclusions : The procedure for wide visualization of the pharynx provided an excellent endoscopic field of view of pharynx and was useful to detect the very early superficial type of SCCP. Routine application of these procedures in endoscopic screening of these high risk individuals will yield an extremely high rate of detection of SCCs in the oral cavity and pharynx as well as the esophagus.

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Duodenal somatostatinoma is a relatively rare endocrine tumor and is associated with von Recklinghausen's disease. We report herein on the case of 36-year-old female who presented with upper gastrointestinal hemorrhage due to a duodenal somatostatinoma. She had café-au-lait spots and multiple subcutaneous neurofibromas. Endoscopic examination revealed a tumor with a hemorrhagic ulcer in the descending duodenum. The ulcer improved with conservative treatment, and a pylorus-preserving pancreaticoduodenectomy was performed. Pathological examination confirmed a carcinoid tumor with invasion of the pancreatic head and lymph node metastasis. Immunohistochemical analyses revealed that the tumor cells were positive for chromogranin A and somatostatin. The final diagnosis was a duodenal somatostatinoma associated with von Recklinghausen's disease.

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We report herein on a 59-year-old female patient. After a marking clip had been applied proximally to a sigmoid colon cancer lesion for scheduled laparoscopic sigmoidectomy, the patient went home. A few hours later, she had abdominal pain and was diagnosed as having perforation of the sigmoid colon. She underwent an emergency sigmoidectomy operation. In conclusion, some procedures are required to prevent the complication such as seen in the present case study.

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A 42-year-old man with ulcerative colitis (UC) had been treated with salazosulfapyridine (SASP) and probiotics for the previous 19 years since the initial diagnosis in 1990. He had a good clinical course. Colonoscopy was performed in 2006 to examine the etiology of hemorrhagic diarrhea and abdominal pain with multiple spheroid-shaped elevated lesions being observed in the ascending colon. The patient was diagnosed as having pneumatosis cystoides intestinalis(PCI). Colonoscopy was performed in 2009 for the positive fecal occult blood test, and proved to be remission of the UC. The PCI lesions were however seen to have fused and had increased in size, up to 20 mm in diameter. We report herein on our case using literature reviews on PCI, complicated with UC, and we show that only 21 cases with these findings have been reported.

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A 58-year-old woman had abdominal pain followed by fever and watery diarrhea. Three days later, the abdominal pain was localized to the right lower quadrant and was exacerbated ; this led to hospitalization. On the day after admission, colonoscopy revealed the presence of multiple ulcers with redness and marked edematous swelling in the cecum. Examination of a biopsy sample obtained from the lesion showed a ghost-like appearance, and the bacterial culture was negative. These findings taken together with the endoscopic findings, led to a diagnosis of ischemic colitis. We herein a case of ischemic colitis of the cecum ; this type of case is very rare, and the present case is even more rare because it is of the transient type.

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We experienced three cases of prostate cancer which presented with an annular stricture of the rectum. Case 1 : A 65-year-old man suspected of having rectal cancer was referred to our department. He was diagnosed as having rectal involvement secondary to prostatic cancer from the high level of his serum PSA level and the positive PSA staining of the rectal biopsy specimen. Case 2 : An 82-year-old man suspected of having an intestinal obstruction due to rectal cancer was referred to our department and sigmoid colostomy was performed. Finally we diagnosed his condition as a rectal stricture secondary to prostatic cancer based on the findings of the prostate biopsy. Cases of prostate cancer directly invading the rectum are rare, however sometimes an annular stricture exists and the patients have dyschezia. Serum PSA and PSA staining of rectal biopsy specimens are useful diagnostic tools in these cases.

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A 52 year old man presented with purpura on his lower limbs, abdominal pain, and melena. He was subsequently diagnosed as having Henoch-Schönlein purpura. Two days after admission, he was diagnosed as having acute pancreatitis-related complications based on the elevated serum levels of amylase and lipase, and slight pancreatic enlargement as seen on abdominal CT images. Following administration of predonisolone and gabexate mesylate the acute pancreatitis improved concomitantly with improvement of the Henoch-Schönlein purpura. As regarding the cause of abdominal pain, we should treat pancreatitis rapidly and adequately, because Henoch-Schönlein purpura is rarely associated with acute pancreatitis.

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Endoscopic placement of a self-expandable metallic stent (SEMS) is a widely accepted palliative therapy in patients with an unresectable malignant biliary stricture. The axial force of the SEMS is considered to be one of the causes of complications associated with stent placement. Recently, a new covered biliary stent (WallFlex Biliary RX Stent) having a lower axial force has become commercially available. We evaluated the efficacy and safety of this new covered biliary stent in 21 patients (mean age, 77 ± 12 yrs ; 11 males, 10 females). Twelve patients had pancreatic cancer, 7 had bile duct cancer, and 2 had lymph node metastases. Stents were placed transpapillary in 19 patients. The remaining 2 patients underwent transgastric or transduodenal stent placement utilizing the endosonography-guided biliary drainage route. In the former 19 cases (mean follow-up duration, 102 days), stent placement was successful and improvement of jaundice was obtained in all patients. Early complications and late complications occurred in 21% (3 pancreatitis, 1 cholecystitis) and 16% (2 cholecystitis, 2 migration, 1 bleeding, 1 occlusion) of the cases, respectively. During follow-up, stent occlusion was observed in 5.3%. The remaining 2 patients achieved alleviation of their jaundice. Early and late complications did not occur during follow-up (follow-up duration, 124 days and 327 days).

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Endoscopic ultrasound-guided fine needle aspiration (EUS—FNA) has been recognized worldwide as a useful modality to enhance the accuracy of biopsy, diagnosis and treatment of lesions with few complications, since Vilmann reported the first procedure. In this article, the learning tools, indications and contraindications, essential anatomy, sedation, pitfalls and knack, the choice of the needles, and patient care after EUS-FNA procedures are described, including the history and present status of EUS-FNA in the Medical University of South Carolina. EUS—FNA clearly enhances the accuracy compared with EUS imaging alone, and has the potential to influence the correct diagnosis of the patients' conditions, which will contribute to the choice of the most appropriate therapeutic approach. The authors believe that EUS-FNA should be more prevalent in Japan, including therapeutic procedures using the EUS-FNA technique such as celiac plexus injection, pseudocyst, biliary duct drainage, and so on.

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