Percutaneous endoscopic gastrostomy (PEG) is an endoscopic surgery first reported by Ponsky and Gauderer in 1980. Due to its safety, convenience, and economy it has already spread worldwide as the first choice for gastrogavage in treating oral ingestion difficulties due to disease and for decompression in treating malignant bowel obstruction. In Japan, such actions as the development of new techniques in PEG surgery, innovations in catheter replacement, country-wide public awareness activities regarding after-care, and improvements in nutritional care through the development and spread of Nutrition Support Teams have resulted in improvements in patients' quality of life and achieved long-term prognoses unparalleled in the world. On the other hand, we also see a movement to re-examine the suitability of PEG from an ethical point of view in patients such as those in the final stages of dementia. Further discussion is needed on this issue.
In addition, one characteristic specific to PEG is that in general the endoscopist performing the procedure and the doctor in charge of after-care are different. The surgical (acute care hospitals) and after-care facilities (long-term care, geriatric health services facilities, private homes) also differ, easily leading to problems. Because of this, we need medical care from a multi-disciplinary team and with local coordination.

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Aim : To assess the efficacy of nafamostat mesylate in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.
Methods : Included in this study were 250 naive papilla patients without pancreatitis or gastrectomy out of 570 consecutive patients who underwent ERCP without prophylactic 20 mg/day of nafamostat mesylate administration (group A) and 250 naive papilla patients without pancreatitis or gastrectomy out of 586 consecutive patients with such administration (group B). The incidences of post-ERCP pancreatitis (PEP) and hyperamylasemia in each group were retrospectively investigated. Risk factors for the development of PEP were also evaluated.
Results : There was no significant difference in the incidences of PEP and hyperamylasemia between group A and group B (4% vs. 4%, p = 1.0 ; 18% vs. 18%, p = 0.91, respectively). In group A, nafamostat mesylate was administered in only 12% of the cases based on the serum amylase level 3 hours after ERCP and clinical manifestations. Multivariate analysis revealed that the only risk factor for PEP was the requirement of over 45 minutes for ERCP. Conclusion : It was suggested that prophylactic 20 mg/day of nafamostat mesylate administration in all ERCP cases does not influence the incidence of PEP.

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A 20-year-old woman was referred to our hospital with epigastric pain and leg edema. Laboratory test revealed eosinophilia (7.8% of WBC) and hypoproteinemia (TP 4.0 g/dl, Alb 2.3 g/dl). Upper gastrointestinal endoscopy showed rugal folds with erythema and erosions in the body of the stomach but not in the esophagus or duodenum. Microscopic examination of the biopsied specimens taken from the stomach, terminal ileum and colon showed eosinophilic infiltration. Ultrasonography and computed tomography revealed slight ascites and thickening of the stomach wall. Protein loss to the gastrointestinal tract was observed by abdominal scintigraphy with 99mTc-DTPA-HSA. Therefore, we diagnosed the patient as having eosinophilic gastroenteritis with protein-losing gastroenteropathy. Clinical symptoms and laboratory findings had improved following treatment with a proton pump inhibitor and mucosal protectant.

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A 64-year-old woman was found to have a submucosal mass 6 cm in diameter in the gastric body by upper gastrointestinal tract radiography. She was referred to our hospital for further examination and treatment. Endoscopic examination showed a submucosal tumor with focal ulceration in the gastric body. Abdominal computed tomography revealed thickening of the gastric wall, bilateral ovarian mass without enlargement, peritoneal metastasis, and a mass 4 cm in diameter in the Douglas pouch. She underwent endosonography-guided fine needle aspiration and was diagnosed with primary peritoneal carcinoma and gastric metastasis. After neoadjuvant chemotherapy with paclitaxel and carboplatin, she underwent debulking surgery.

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We report here a case of a benign fibroblastic polyp (BFP) of the sigmoid colon. Colonoscopy was performed for a 65-year-old man for the purpose of screening for colorectal cancer. Screening revealed a small (5 mm) protruding polyp that appeared like a submucosal tumor at the sigmoid colon, and endoscopic mucosal resection was performed. In hematoxylin and eosin stained sections there was a proliferation of monomorphic benign-appearing spindle cells in the lamina propria. Immunohistochemical staining revealed strong positivity for vimentin in the spindle cells. With the exception of focal positivity for CD34, staining for epithelial membrane antigen, alpha-smooth muscle actin, desmin, S-100, c-Kit and PDGF was negative. Ki-67 labeling demonstrated low positivity. These features were consistent with the diagnosis of BFP. BFP is a recently described entity and its true nature or etiology is still unknown. The differential diagnosis of BFP includes the presence of other spindle cell proliferations in the gastrointestinal tract, which may have features of mucosal polyps or submucosal tumors, including smooth muscle tumors, gastrointestinal stromal tumors, neurofibroma, schwannoma, intestinal perineurioma, and inflammatory fibroid polyps. This is the first case report of BFP in Japan.

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A 22-year-old female patient was admitted to our hospital with complaints of lower abdominal pain and hematochezia. A mass measuring 3 cm in diameter was detected outside of the anus. The mass was manually reducted into the rectum, which resulted in rapid relief of abdominal pain. Sigmoidoscopy revealed a polyp with a nodulous head in the sigmoid colon. An intussusception caused by the sigmoid colon polyp was strongly suspected. Polypectomy was performed, and the patient's postoperative course was uneventful during a 1-month follow-up period. An adult intussusception caused by a sigmoid colon polyp that is successfully resected with endoscopy is extremely rare. Here, we describe one such case and review the literature.

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An 88-year-old woman visited our hospital with complaints of anorexia and weight loss. Computed tomography suggested colon cancer of the ascending colon with Douglas pouch metastasis and lung and liver metastases. Colonoscopy was performed to confirm the diagnosis of ascending colon cancer, but the colonoscope could not be passed through the rectosigmoid region because of the presence of a stenotic mass resulting from the Douglas pouch metastasis. A self-expandable metallic stent (SEMS) was inserted at this site through the scope. Expansion of the stenosis with the SEMS allowed the scope to pass through this stenotic region and approach the ascending colon, resulting in the diagnosis of ascending colon cancer, which had obstructed the passage of the scope. A second SEMS was subsequently inserted into the area of the tumor in the ascending colon for decompression. Herein, we report a case in which SEMS contributed to the diagnosis of a lesion located proximal to the stenosis and allowed for decompression of the colon in patients with two incurable malignant colonic obstructions, thereby avoiding surgery and improving quality of life. We also report a literature review of definitive palliation by using SEMS in patients with incurable malignant colon obstructions.

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Two patients who had gastrointestinal ulceration due to sorafenib presented at our department. Case 1 : A 69-year-old male was admitted to our hospital for the treatment of anemia, which occurred 50 days after he started sorafenib treatment. Upper gastrointestinal endoscopic findings revealed ulcerative lesions in the posterior wall of the upper body of the stomach. Case 2 : A 62-year-old male was admitted for bloody stool that occurred 60 days after the start of sorafenib administration. Colonoscopic findings revealed ulcerative lesions in the sigmoid colon. Both of the ulcerative lesions were shallow, and a colonic ulcer was located along the longitudinal axis of the intestine. After stopping sorafenib administration, the symptoms disappeared rapidly in both cases. It was suggested that sorafenib might induce thrombosis via the inhibition of vascular endothelial growth factor and provoke ischemic gastrointestinal ulceration.

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We report a case of biliary pseudolithiasis caused by ceftriaxone in a 54-year-old woman undergoing hemodialysis. She was admitted with diverculitis, and ceftriaxone was given. After 13 days, she complained of right hypochondriac pain with elevated liver enzyme levels. CT revealed high density structures in the gallbladder and common bile duct, which were not detected at admission. Endoscopic biliary drainage was performed, and these structures disappeared 33 days after admission. Biliary pseudolithiasis has been reported to disappear a short time after discontinuing ceftriaxone. However, biliary drainage is recommended in cases of biliary obstruction.

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The patient was a 54-year-old woman with acute cholangitis. As cannulation for the bile duct was difficult, we chose to place a pancreatic stent to prevent post-ERCP pancreatitis. From abdominal CT, we found that the pancreatic stent had migrated into the body of the pancreas and decided to remove it. We chose to use the GooseNeck^TM Microsnare, which is commonly used for vascular interventional procedures because the duct was so small that an endoscopic procedure seemed difficult. Our attempt at removal was successful. Cases of a migrated pancreatic stent might increase as endoscopic pancreatic stenting has been covered by insurance beginning in 2012. To our knowledge the use of the GooseNeck^TM Microsnare for this purpose has not been reported yet. Here we report a case of a migrated pancreatic stent that was easily removed by the use of such a tool.

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The improved Mucosectome was released in October 2010. This device provides greatly improved rotation. Also, the device and handle are integrated, which enhances visibility of the marker on the posterior side. We performed endoscopic submucosal dissection (average lesion size 33.6 mm) for 23 colorectal neoplasms from January to December 2011. We found that the device could be used safely, with an average operative time of 54 minutes, en bloc resection rate of 100%, no perforations, and only one case of post-procedural bleeding. The number of disposable knives, not counting the needle knife, was 1.13. Intraoperative hemostasis was required 2.4 times, less than with the conventional method (4.5 times with a flush knife). Mucosectome was considered to be an excellent treatment instrument in terms of not only safety, but also economic efficiency.

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Dietary saturated fatty acid (SFA) intake is an important risk factor for ischemic heart disease, non-alcoholic steatohepatitis and carcinogenesis. Dietary SFAs are absorbed by small intestinal villi after their hydrolysis from triacylglycerols by pancreatic lipase. ¹³CO₂ breath tests, based on nondispersive infrared spectrometry, allow noninvasive quantitation of physiological processes. The breath ¹³CO₂ assay after loading of ¹³C-labeled sodium palmitate, which is one of the most abundant dietary SFAs, is designed to assess the absorption of dietary SFAs from the small intestine. Traditionally, the breath ¹³CO₂ assay after loading of ¹³C-labeled sodium palmitate requires its oral administration. Using gastrointestinal endoscopy, we administered ¹³C-labeled sodium palmitate directly into the duodenum to avoid the influence of gastric emptying. Palmitic acid is an SFA that is a solid at room temperature and is insoluble in water. However, ¹³C-labeled sodium palmitate can be maintained in a liquid state during administration by using the emulsifying effect of RACOL Liquid^® (Otsuka Pharmaceutical Factory, Inc.). Specifically, 200 mg of ¹³C sodium palmitate (Cambridge Isotope Laboratories, Inc.) is dissolved in 20 mL distilled water, heated to 70°C, and then blended with 20 mL warmed (50°C) RACOL Liquid^®, which is used to keep the fatty acid in a liquid state. After an overnight fast of 12 h, all subjects received ¹³C-labeled sodium palmitate in the horizontal portion of the duodenum using an upper gastrointestinal tract endoscope. Thereafter breath samples were collected every 30 min over a period of 6 h. Breath samples were also collected before loading. Samples were analyzed using nondispersive infrared spectrometry. Changes in the ¹³CO₂/¹²CO₂ ratio from baseline were expressed as Δ (‰). The time-dependent change in the Δ (‰) was used as a marker of the absorption of ¹³C-labeled SFAs from the small intestine. The use of this endoscopic approach for the breath ¹³CO₂ assay after loading of ¹³CO₂-labeled sodium palmitate results in a more precise evaluation of the absorption of dietary SFAs from the small intestine than that obtained using the traditional method of administering it orally.

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Endoscopic balloon dilatation (EBD) is a minimally invasive therapy for intestinal strictures that can eliminate the need for surgery and improve the quality of life. EBD is regarded as a safe and effective procedure mainly for the management of benign intestinal strictures. In recent years, the development of balloon-assisted enteroscopy (double-balloon endoscopy and single-balloon endoscopy) has enabled the use of EBD for small intestinal strictures as well as for esophageal, gastric, duodenal and colonic strictures. Through-the-scope (TTS) balloon is now frequently used for EBD because the technique is easier than that using the over-the-wire (OTW) balloon. In this article, indications, therapeutic techniques and complications of EBD for intestinal strictures using the TTS balloon are described. In order to perform EBD successfully, it is important to carefully assess whether the patient's stricture meets the inclusion criteria before the balloon dilatation therapy. It is also important to perform multi-step inflation with a gradually increasing diameter under minimal conscious sedation. This technique can reduce complications such as massive bleeding and perforation. In this paper, the effectiveness of EBD for Crohn's strictures is also discussed. In recent years, a few reports have described the usefulness and efficacy of EBD for small intestinal strictures in Crohn's disease patients. This procedure may be of significant benefit and should be considered as a useful and effective alternative to surgery. Further investigation will be necessary to confirm the benefit of this procedure.

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