Endoscopic retrograde cholangiopancreatography (ERCP) and associated procedures are difficult to perform in patients with a surgically altered anatomy because of the extremely long length of afferent limbs that must be traversed to reach the major papilla. A new insertion method using a double-balloon endoscope or a single-balloon endoscope enables easier access to the afferent duodenal loop in a patient with Roux-en Y anastomosis. However, no standard procedure has been established, so it is desirable to accumulate more cases in the future in order to overcome various problems with such endoscopes and other treatment devices. It is hoped this will lead to further improvements in these endoscopes and devices.

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[Background] Laparoscopy and endoscopy cooperative surgery (LECS) for gastric submucosal tumor (SMT) resection has been reported by several investigators. We investigated the safety and usefulness of LECS for resection of gastric SMT in the cardiac region of the stomach.
[Methods] A total of 15 patients with gastric SMT in the cardiac region of the stomach underwent LECS between June 2006 and April 2013. We examined the patients' backgrounds, characteristics of the lesion, operative outcomes, and postoperative courses.
[Results] The mean tumor size was 3.5 cm. The circumferential extension of the tumor at the esophagogastric junction (EGJ) was less than 50% in 11 patients and 50% or more in four patients. We could not complete LECS in the four patients with circumferential extension of the tumor exceeding 50% at the EGJ, necessitating intraoperative conversion of the method to open surgery or proximal gastrectomy. The patients in whom LECS was completed had no complications, while three of the four patients in whom LECS was not completed experienced complications such as suture failure, intra-abdominal abscess, or anastomosis stricture.
[Conclusion] LECS is useful for resection of gastric SMT in the cardiac region of the stomach when circumferential extension of the tumor at the EGJ is less than 50%.

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A 73-year-old male with colon cancer was referred to our hospital, and gastrointestinal endoscopy for preoperative screening revealed a lesion of around 15mm at the esophagogastric junction with a highly protruding appearance. Xanthoma was diagnosed, and follow-up examination every three to six months showed no evidence of malignancy.
Magnifying endoscopy with narrow band imaging was performed at three-year follow-up, and showed malignant findings of xanthoma using the vessel-surface (VS) classification system. Adenocarcinoma was histologically diagnosed.
Magnifying endoscopy with narrow band imaging is useful for observation of gastric xanthoma with atypical appearance and the possibility of malignant formation.

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A 75-year-old male was referred to our hospital for further evaluation of an esophageal submucosal tumor. He was asymptomatic. Computed tomography revealed a completely calcified, 34 mm × 18 mm mass at the posterior mediastinum. Endoscopic observations revealed an elevated lesion in the anterior wall of the esophagus, localized 28 cm from the incisor teeth and covered with normal mucosa. Mucosal cutting biopsy was performed. Histopathological examination of the biopsy specimen confirmed the diagnosis of esophageal leiomyoma. He has undergone follow-up observation but no treatment. Esophageal leiomyoma with diffuse calcification is rare, and preoperative diagnosis is difficult. Mucosal cutting biopsy was useful for diagnosis in this case.

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An 81-year-old man who complained of appetite loss underwent esophagogastroscopy and three large gastric bezoars were found. Considering that he had a habit of eating persimmons, we diagnosed diospyrobezoar. The bezoars were so hard that dissolution with cola and fragmentation using a regular endoscope with grasping forceps, polypectomy snare and lithotripsy basket were ineffective. We used a double channel endoscope and pressed the grasping forceps that had been inserted into one channel against a bezoar held with a polypectomy snare that had been inserted into the other channel with parallel force in opposite directions. This technique was effective for fragmentation and we could remove all of the bezoars. We consider that this method can be performed if a double channel endoscope is available, and is very effective for the treatment of large bezoars resistant to dissolution with cola and fragmentation with a regular endoscope.

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A 51-year-old male patient presented to our hospital with suspected gastric amyloidosis identified during a medical check-up at another hospital. Upper gastrointestinal endoscopy revealed a depressed lesion of approximately 5 × 3 cm with a concave surface and a clear border beside the lesser curvature of the frontal wall of the mid-gastric corpus. Amyloid deposition (AL type) was confirmed by biopsy. As amyloid deposits were not observed in regions other than the stomach on other examinations, including PET-CT, the lesion was diagnosed as localized gastric amyloidosis with an ulcerative lesion (IIc+IIa like). A similar lesion had been identified in our patient by upper gastrointestinal endoscopy and biopsy at the other hospital six years previously. This paper reports a case of localized gastric amyloidosis without progression over a 6-year period.

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A 77-year-old Japanese man was referred to Kagawa Prefectural Central Hospital for further investigation of a positive fecal occult blood test. Colonoscopy revealed an elevated lesion of 35 mm in diameter in the ascending colon. The lesion had a submucosal tumor-like morphology, lacking erosions or ulcers. Histological examination of the biopsy specimen revealed dense infiltration of small-sized neoplastic lymphoid cells. Based on the immunohistochemical examinations, the colonic tumor was diagnosed as follicular lymphoma. CT scanning revealed systemic lymphadenopathy in addition to the colonic tumor. Six courses of CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy plus rituximab were administered as the first-line treatment. After completion of the regimen, the colonic tumor had disappeared and the lymphadenopathy had partially regressed. However, a mesenteric lymph node had become enlarged. Bendamustine was therefore administered to treat the relapse of follicular lymphoma. Among the various parts of the gastrointestinal tract, the small intestines (especially the duodenum) are the most common site of follicular lymphoma involvement, and the colorectum is less frequently affected. This paper illustrates a rare case of systemic follicular lymphoma with colonic involvement.

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We report an 82-year-old woman with a pelvic abscess that was successfully treated by endoscopic ultrasound (EUS)-guided transrectal drainage. She presented to our emergency room with fever and lower abdominal pain two months after bilateral adnexectomy and hysterectomy for tubo-ovarian abscess. CT revealed an abscess cavity of 8 cm in diameter between the urinary bladder and the rectum. As the abscess was located close to the rectum and left colon wall, EUS-guided transrectal drainage was performed. EUS showed evidence of perirectal fluid collection, and the abscess was punctured with a 19-gauge EUS-FNA needle, followed by insertion of a 6Fr drainage catheter within the abscess cavity. She became afebrile within 24 hours after drainage and the size of the abscess decreased significantly on follow-up CT one week later. The external catheter was exchanged to a 7Fr internal stent, which was spontaneously expelled after 2 weeks. One month later, follow-up CT showed complete resolution of the abscess. EUS-guided transrectal drainage appears to be an effective non-surgical intervention for postoperative pelvic abscesses.

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Due to distal stenosis, preoperative evaluation of the entire colon in patients with obstructive colorectal cancer is not possible. However, the prevalence of synchronous multiple cancers is relatively high in patients with obstructive colorectal cancer, and thus accurate preoperative evaluation of the proximal colon is very important. Since 2012, the use of a self-expanding colorectal stent as a bridge to surgery (BTS) has become widespread in Japan. Five patients with obstructive colorectal cancer who successfully underwent total colonoscopy through the stent using a small-caliber colonoscopy are reported. Three of the five patients were found to have another cancer (one advanced and two early cancers) in the proximal colon, and simultaneous resection was performed in the two cases with early cancers. Preoperative endoscopic evaluation after inserting a self-expanding colorectal stent is clinically very useful both to diagnose multiple synchronous lesions and to determine the safety margin for resection.

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We have described endoscopic lithotripsy procedures for pancreatic stones. Endoscopic pancreatic sphincterotomy, on the other hand, is indicated for minimally invasive removal of pancreatic calculi of 6mm or less in diameter, in symptomatic patients. (When stone diameters exceed 7mm, we perform endoscopic lithotripsy after fragmentation with extracorporeal shock-wave lithotripsy.) Two approaches can be used for endoscopic pancreatic sphincterotomy : either performing it after first endoscopically widening the sphincter of Oddi, or carrying out endoscopic pancreatic sphincterotomy directly. Performing endoscopic sphincterotomy at the papilla of Vater prior to endoscopic pancreatic sphincterotomy, can avoid transient obstruction of the common bile duct by ampullary edema after the pancreatic sphincter procedure. However, safe cannulation of the pancreatic duct is easier to perform than cannulating the common bile duct, and can be performed readily by even a relatively inexperienced endoscopist. After endoscopic pancreatic sphincterotomy, we insert a basket catheter into the pancreatic duct along a guide wire in order to remove pancreatic stones while protecting the wall of the pancreatic duct. Significant adverse effects of endoscopic pancreatic sphincterotomy may include bleeding, acute pancreatitis, and perforation. Endoscopic treatment of pancreatolithiasis is well established and provides good results. However, its limitations require flexibility to convert to open surgery if necessary to avoid missing a therapeutic opportunity.

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[Purpose] Digestive therapeutic endoscopy (DTE) has become widely performed in Japan since the 1980's. The Digestive Therapeutic Endoscopy Conference of Yamagata Prefecture (DTECYP) has been held since 1991. Staring that year, physicians who attended the conference were asked to fill out questionnaires about DTEs performed at their hospitals. The purposes of this study were to understand the present condition, and analyze the trend of DTEs performed over the last 20 years.
[Methods] The DTECYP has been held biannually between 1991 and 2002, and annually since 2003. Questionnaires about the annual number of DTEs performed at their hospitals were sent to physicians at those hospitals and collected for recording and analysis. We analyzed the accumulated data of 20 years from 1990 to 2009.
[Results] The annual number of DTE procedures performed in Yamagata prefecture increased from 2,823 procedures in 1990 to 11,313 procedures in 2009. The annual number of DTE procedures performed increased 4.0-fold over the 20-year period. The number of hospitals whose physicians attended the DTECYP increased from 23 to 32. The three most frequently performed procedures were endoscopic mucosal resection (EMR) in the lower GI tract (4,724 procedures), endoscopic hemostasis (1,346 procedures), and percutaneous endoscopic gastrostomy (PEG) (1,252 procedures). The annual number of DTE procedures for endoscopic retrieval of bile duct stones increased at the fastest rate ; 33 procedures were performed in 1992 and 683 in 2009, for a 20.7-fold increase. Next were endoscopic submucosal dissection (ESD) in the upper GI tract, which increased 15.7 times, and endoscopic retrograde biliary drainage (ERBD), which increased 15.6 times.
[Conclusions] The annual number of DTE procedures performed in Yamagata prefecture increased 4.0-fold from 1990 to 2009. DTE was performed most frequently for EMR of the lower GI tract, endoscopic hemostasis and PEG. The annual numbers of DTE procedures for endoscopic retrieval of bile duct stones, ESD in the upper GI tract, and ERBD increased at the fastest rates. Such procedures have become more frequently performed in Yamagata prefecture, one of the local districts in Japan with a population of 1.15 million.

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