Chemoradiotherapy (CRT) or radiotherapy (RT) is a potential optional therapy for esophageal squamous cell carcinoma, because radiation-based therapy is conservative and less invasive. However, radiation-based therapy for esophageal cancer is disadvantageous because of a high locoregional failure rate. Detecting small recurrent cancer at the primary site at the early stage is necessary for potential salvage treatment. Early primary-site recurrence of esophageal cancer after a complete response to radiation-based therapy is detectable with frequent endoscopic surveillance, especially during the two-year period after a complete response. The appearance of a submucosal tumor is a useful endoscopic sign of early recurrence.
Useful salvage therapies for recurrence lesion after radiotherapy include endoscopy-based therapy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD) and photodynamic therapy (PDT). The criteria for EMR/ESD are : 1) no deep ulcer, 2) clinically defined N0 and M0 by endoscopic ultrasound (EUS) and computed tomography (CT), 3) definite or suspected cancerous mass limited to the submucosa, and 4) an expectation that complete resection can be achieved by endoscopic resection. On the other hand, the criteria for PDT are : 1) clinically defined N0 and M0 by EUS and CT, 2) local failed lesion limited within the muscularis propria (T2), 3) patient refusal of salvage esophagectomy or lack of tolerability for salvage esophagectomy. Salvage therapy is performed on local failure lesions that meet at least one of the following criteria : a) histologically proven carcinoma by biopsy specimen, b) emerged ulceration in the lesions, c) enlarged submucosal tumor-like protrusion in the lesion, d) presence of a heteroechoic solid component on EUS observation.

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In this case report of extrusion of an interlocking plate into the esophagus of a patient 17 years after anterior cervical fixation, the authors describe a rare complication and review the literature on this topic. A 70-year-old man underwent anterior cervical fixation using an interlocking plate and wire. Six years after the operation, endoscopy revealed esophageal perforation by an interlocking plate without causing any symptoms and the patient was closely followed up since. Seventeen years after the operation, the patient presented with severe dysphagia. Chest radiographic findings indicated that an interlocking plate had fallen through the esophagus. The interlocking plate was removed endoscopically and the patient was discharged without any symptoms.

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A 79-year-old man underwent colonoscopy for follow-up of colon adenoma. Conventional endoscopic view and chromoendoscopic view with indigo carmine dye showed a slightly reddish, protruded lesion, 3 mm in diameter, and a surrounding flat elevated lesion, 35 mm in diameter, with a mucous cap. Narrow band imaging with magnifying endoscopic view showed a surface pattern that was vague and irregular microvessel features in the protruded lesion and a regular surface pattern and regular microvessel features in the flat elevated lesion. Magnifying chromoendoscopic view with crystal violet staining showed an irregular tubular pit in the protruded lesion and a regular open-oval pit in the flat elevated lesion. We made the diagnosis of cancer with serrated lesion and performed endoscopic submucosal dissection. Histopathologic cross-section revealed well-differentiated tubular adenocarcinoma in the protruded lesion, and serrated lesion with irregular branching crypt and crypt dilation in the flat elevated lesion. The histological diagnosis was intramucosal colorectal cancer in sessile serrated adenoma/polyp (SSA/P). This case suggests that magnifying chromoendoscopy and NBI endoscopy are useful methods for diagnosis of colorectal cancer with SSA/P.

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An 82-year-old man with severe renal dysfunction was admitted because of epigastric pain. Hematological examination revealed elevated levels of hepatic and biliary tract enzymes, and computed tomography showed a hyper-dense lesion with an area of 18×13 mm in the common bile duct. The lesion was diagnosed as a common bile duct stone, and endoscopic retrograde cholangiopancreatography was performed to remove the stone. Following endoscopic sphincterotomy, papillary large balloon dilation was performed using a 10-12 mm balloon catheter. We expanded the balloon to 10 mm, at a pressure of 3 atmospheres, until the notch disappeared. However, bleeding occurred in spurts from the papilla and we were unable to determine the primary bleeding point. We immediately tried to obtain endoscopic hemostasis using a large balloon catheter to provide compression at the bleeding point. Despite maintaining pressure for >30 min with the catheter, we could not control the bleeding. Because our patient was of advanced age with severe complications, we had to adopt a minimally invasive treatment. Therefore, we decided to attempt endoscopic hemostasis by placing a partially-covered self-expandable metallic stent in the distal bile duct [10mm diameter and 4cm length (Boston Scientific WallflexTM)]. The bleeding ceased, and we were able to avoid unnecessary surgery and interventional radiology. The stent was withdrawn 21 days later without complications.

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Diagnosis and treatment of biliary tract disease require an intraductal radiocontrast agent. However, some patients show severe allergic reactions to commonly-used iodinated contrast agents. Here, we used carbon dioxide (CO₂) as an alternative radiocontrast agent in patients who are allergic to iodine-based contrast medium in the diagnosis and treatment of malignant biliary obstruction caused by cancer of the head of the pancreas. We were able to obtain a good cholangiogram and perform placement of a metal stent by using CO₂ cholangiography. Therefore, CO₂ cholangiography is a good alternative to iodine-based cholangiography in patients who are allergic to iodine.

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Conventionally, as a method of introducing an intranasal drainage tube, the “conventional method” using a laryngoscope has been common. However, recently, the usefulness of the “roping method” which uses a soft catheter and a guidewire (GW), and that of the “GW single method” which introduces the tube with only a GW, have been reported. We experienced 110 cases of intranasal introduction of a nasal drainage tube by the “guidewire single method”.
We studied 110 consecutive patients in whom a nasal drainage tube was inserted. We decided to use the “roping method” if the tube could not be inserted by the GW single method within 5 minutes. Furthermore, we decided to perform the “conventional method” if the tube could not be introduced by the roping method within 5 minutes. We measured time A [from the beginning to introduction of the GW outside the oral cavity], time B [from the introduction of the GW outside the oral cavity to final placement of the drainage tube], time C [time A+time B ; from the beginning to the end], and the length of time of undergoing X-ray fluoroscopic observation. We studied the success rate of the “GW single method”, complications, and factors affecting time A to C.
The median time of A, B, and C and of undergoing X-ray fluoroscopic observation were 58.0seconds, 61.0seconds, 124seconds, and 59.5 seconds, respectively. The success rate of the “GW single method” was 99.1%. Serious complications were not recognized. We studied several factors such as age, sex, height, weight, body mass index (BMI), examination type, drainage tube diameter, and physician. BMI was a factor affecting time B. Although the physician was a factor affecting time A to C and the length of time of performing X-ray fluoroscopic observation, this difference was considered to disappear with experience.
The “GW single method” was considered to be a simple method that can be performed safely.

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There are no special techniques for conquering difficult cases of colonoscopy ; careful insertion and being true to basic techniques are most important in these cases. As flexible and yielding scopes are more often useful in difficult cases, the PCF-PQ260L/I scope is frequently used at our center. The examiner must always think of each examination as a challenge and must not perform the procedures incautiously. It is important to always pay attention to the sensation of the hands, as there is a limit to the improvement of insertion techniques if the minute sensations of the hands are not appreciated. Striving to perform less painful procedures will make the examiner conscious of the location and situation of the scope such as twisting, bending and looping, and in the end this will be the key factor in improving insertion techniques.

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