Background and Aims : In recent years, the majority of patients in Japan prefer to undergo colonoscopy without pain and anxiety. Our aims were to evaluate and compare the efficacy and safety of, and patient satisfaction with propofol sedation with those of non-sedation or midazolam/pentazocine sedation administered during outpatient colonoscopy. Results : Between December 2006 and August 2008, we performed a total of 661 colonoscopic examinations. Among them, 241 colonoscopic examinations were performed with propofol sedation, 236 with midazolam/pentazocine sedation, and 184 with no sedation. The systolic blood pressure (SBP) decreased in patients with sedation ; especially in patients with propofol sedation, the SBP decreased by a mean of 42%. The SBP increased by a mean of 11% in patients without sedation. The oxygen saturation decreased in patients with sedation ; especially in those with midazolam/pentazocine sedation, the oxygen saturation decreased by a mean of 39%. Pain control was better in patients with sedation ; especially in patients with midazolam/pentazocine sedation, pain control was better by a mean of 93% compared with that in the no sedation group. The recovery time was significantly shorter in patients with propofol sedation than in those with midazolam/pentazocine sedation (17min vs. 126min). Adverse events after returning home were more frequent in patients with midazolam/pentazocine sedation ; 21% of patients with midazolam/pentazocine sedation developed adverse events Patients' satisfaction was higher in those with sedation. Conclusion : Endoscopist-administered propofol sedation for outpatient colonoscopy was safe and effective with a low incidence of adverse events during the procedure, shorter recovery time after returning home, and good patient satisfaction levels.

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A 77-year-old woman was admitted to our hospital because of repeated episodes of vomiting and abdominal pain. Computed tomography revealed fluid collection in the stomach and diffuse wall thickening of the antrum. Upper gastrointestinal endoscopy revealed irregular gastric mucosa of the antrum with severe pyloric stenosis. Histological examination of biopsy specimens showed mucosal infiltration of inflammatory cells and eosinophils. We diagnosed the patient with eosinophilic gastritis. After steroid therapy, the irregular-appearing mucosa improved. The pyloric stenosis was treated with multiple endoscopic balloon dilations, and the symptoms of the patient improved. The patient continues to be observed with administration of steroids.

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An 85-year-old man presented to a nearby medical clinic following palpitation and tarry stools. On examination, anemia was detected. To further investigate the cause of these symptoms, he was referred to our hospital. Upper gastrointestinal endoscopy revealed elevated lesions throughout the stomach, and the mucous membrane was rough and hemorrhagic. Under magnifying endoscopy, the lesions demonstrated the absence of a mucosal microsurface pattern. However, a wide and meandering microvascular pattern could be seen along the faint margins of the lesions. Histopathological analysis of a tissue biopsy specimen indicated amyloidosis. AL amyloidosis was suspected at first ; however, a specific staining procedure subsequently revealed that the patient had senile systemic amyloidosis (SSA) caused by transthyretin deposition.

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A 37-year-old male underwent upper gastrointestinal X-ray examination during routine medical checkup, and the X-ray examination revealed an abnormal, large lesion in his stomach. He was referred to our hospital for further examination. Gastrointestinal endoscopy revealed a large gastric bezoar. Since endoscopic extraction and dissolution therapy with Coca-Cola for this bezoar were unsuccessful, we extracted it by laparoscopy and endoscopy cooperative surgery (LECS). When it is difficult to extract a gastric bezoar by minimally invasive treatments such as endoscopic extraction and dissolution therapy, surgical treatment with LECS is useful because it involves only a small incision and the bezoar can be extracted safely and surely.

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A 70-year-old woman with type C liver cirrhosis was admitted to our hospital due to anemia and melena. Contrast-enhanced computed tomography revealed a 5cm-long tumor in the third part of the duodenum and a low-density area indicating the presence of adipose tissue in the tumor. Oral double-balloon endoscopy showed a 5cm-long pedunculated polyp in the third part of the duodenum. After endoscopic polypectomy, histological examination showed that the polyp was covered with normal duodenal mucosa and the mucosal and submucosal components contained loose connective tissues accompanied by venodilation and lymphangiectasia. Since these findings of the resected specimen were compatible with those of colonic muco-submucosal elongated polyp (CMSEP), we diagnosed the polyp as a duodenal MSEP. Duodenal MSEP is rare and this polyp was characterized by marked hyperplasia of adipose tissue within the lesion.

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A 16-year-old female consulted a local doctor due to vomiting and abdominal pain. She was referred to our hospital because intussusception was suspected. Abdominal ultrasonography and CT showed findings of intussusception of the proximal jejunum. Oral small intestinal endoscopy revealed retrograde intussusception of the jejunum. Food residue (eggplant) was observed at the tip of the intussusception, with swelling by edema of the mucosa of the surrounding jejunum. The intussusception naturally recovered after removal of the food residue. Tumors or other lesions were not found in the jejunum. No pathological findings were observed in the biopsied mucosa of the jejunum at the intussusception. We report a case of dietary intussusception in an adolescent with food residue of eggplant. Small intestine endoscopy was useful for the diagnosis and treatment of intussusception of the small intestine in an adolescent patient.

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A 71-year-old man was diagnosed with pancreatic carcinoma from the pancreatic head to the pancreatic body by endoscopic ultrasonography fine-needle aspiration. Since he was found to have duodenal stenosis, he underwent duodenal (bulbus) stenting. While he was receiving chemotherapy with gemcitabine, he complained of high-grade fever. Laboratory results showed a markedly elevated serum C-reactive protein level. Abdominal CT showed dilatation of a pancreatic branch duct and a high density of fat tissue around the pancreas.
We performed endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic pancreatic duct drainage. Purulent pancreatic fluid was drained endoscopically by a 5Fr plastic stent in the main duct, resulting in marked improvement of clinical symptoms. After stenting, his high-grade fever alleviated and his CRP level decreased.

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An 80-year-old man was hospitalized for gallstone pancreatitis in our hospital and he underwent endoscopic sphincterotomy (EST). After EST, we tried to place a pancreatic stent (one-sided pigtail type) to prevent exacerbation of pancreatitis, but the stent migrated into the main pancreatic duct. The proximal edge of the stent was located in a side branch of the pancreatic duct, and we could not retrieve the stent in spite of using a balloon catheter and some forceps. On the third hospital day, we tried to retrieve the stent again. We guided the sheath (5Fr) of a basket catheter for removal of biliary stones (Memory Basket^® Eight Wire) to the distal edge of the stent across the guidewire, and inserted only the wire of a snare for polypectomy (Sensation^TM Medium Stiff Wire) into the sheath. We opened the snare at the far side of the distal side of the stent, could catch the stent and could retrieve it successfully.

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The difficulty of en-bloc resection of a colorectal tumor by ESD is sometimes due to the presence of fibrosis. We examined the causes and endoscopic findings of fibrosis in the submucosal layer (SM) in order to establish an appropriate therapeutic strategy for such lesions. From these observations, we developed a safe ESD technique.
We performed ESD on 778 colorectal tumors in 772 patients (male : female = 457 : 315 ; mean age, 65.6 years). Among these 778 cases, 193 cases were accompanied by fibrosis in the SM. These cases were divided into three groups : absence of fibrosis (type A), fibrosis due to non-malignant causes (due to biopsy, recurrence after EMR, etc. ; type B), and fibrosis due to cancer invasion in the SM (type C). The degree of fibrosis was classified into mild (grade 1), moderate (grade 2), and severe (grade 3). The one-piece resection rates were as follows : type A, 571/585 (97.6%) ; type B-1, 66/69 (95.87%) ; B-2,29/32 (90.6%) ; B-3,18/31 (58.1%) ; type C-1,33/33 (100%) ; C-2,7/8 (87.5%,) ; C-3,10/20 (50%). We experienced two cases (0.26%) of perforation in type B. Tumors accompanied by mild to moderate fibrosis should be carefully dissected just above the muscle layer. In cases accompanied by severe fibrosis (type B-3), we developed a safe ESD technique to overcome these difficulties by identifying the dissection line to be just above the muscle layer in order to complete the ESD procedure. In three type B-3 cases, we used an endo-clip on the muscle layer to prevent perforation before dissection.
The usefulness of ESD for lesions with fibrosis is limited from the viewpoint of safety and curability. For these reasons, we established the Laparoscopy Endoscopy Cooperative Surgery (LECS) procedure to complete safe one-piece resection with adequate surgical margin.

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