Due to continual progress in endoscopes and diagnostics, many superficial cancers of the head and neck have been discovered. According to the criteria for head and neck cancer, superficial cancers are defined as “those in which cancer cells have advanced to the subepithelial layer”. For treatment, the curved laryngoscope developed by Omori is able to open up the larynx, thus permitting endoscopic treatment. Taking into account naked-eye categorization and the depth of invasion, many flat lesions and protruding lesions can be observed, and subepithelial invasion is seen in lesions with prominent protrusions of type 0-I, and those with mixed types, such as type 0-IIa+IIc. In laryngopharyngeal cancer, sufficient evidence regarding the invasion depth of the lesion or its size, and lymph node metastasis cannot be obtained, but at present, with absolute adaptation (1) in the pre-surgical examination, no lymph node metastasis has been observed. (2) Endoscopically, the invasion depth was cancer within the epithelium, and with relative adaptation (1) in the pre-surgical examination, no lymph node metastasis has been observed. It is possible that (2) endoscopically, the invasion depth is that of a subepithelial invasive cancer. By studying long-term records, the possibility of a radical cure of head and neck cancers through localized treatment focusing on endoscopic treatment is suggested. However, going forward, a significant amount of validation is needed, such as diagnosis of invasion depth or evidence of lymph node metastasis, and long-term records must be carefully investigated.

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Background : Endoscopic papillary balloon dilation (EPBD) is associated with a lower risk of hemorrhage and is easier to perform but is associated with higher incidence of pancreatitis than endoscopic sphincterotomy (EST). It is reported that 5-minute EPBD improves the efficacy of stone extraction and reduces the risk of pancreatitis compared with the conventional 1-minute EPBD. Therefore, we conducted a retrospective comparative study of 5-minute EPBD vs. EST with respect to stone extraction and pancreatitis.
Methods : All enrolled cases had bile duct stones of less than 10mm. The consecutive 49 cases treated by 5-minute EPBD from October 2013 to October 2014 were compared with the consecutive 82 cases treated by EST from May 2010 to October 2013. The diameter of the EPBD balloon in this trial was 10mm in all cases.
Results : Mean age was 75.7 yr in the EPBD group and 69.7 yr in the EST group, showing a significant difference. Gender, stone diameter and number of stones did not significantly differ between the two groups. The rate of complete extraction of bile duct stones in the first session was 100% in both groups. Procedure time was approximately 30 minutes in both groups and did not show a significant difference. Pancreatitis was seen in 2.0% of the EPBD group and 6.1% of the EST group, and bleeding occurred only in the EST group (2.4%) although the rates of pancreatitis and bleeding did not show significant differences.
Conclusion : 5-minute EPBD was associated with high performance of stone extraction and low incidence of pancreatitis. It may be the first choice as a method for extracting bile duct stones of less than 10 mm because we can expect better long-term outcomes with EPBD than with EST. However, a randomized trial is needed to reveal long-term outcomes.

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A 39-year-old man with alcoholic cirrhosis was hospitalized because of hematemesis. In the previous 2 years, he had frequently experienced hemorrhage from esophageal varices. He had undergone endoscopic variceal ligation or endoscopic injection sclerotherapy each time. Emergency endoscopic examination at the time of presentation showed an arterial hemorrhagic esophageal ulcer in the lower esophagus. We attempted endoscopic hemostasis using a hemoclip, but were not successful. Abdominal angiography showed hemorrhage from a branch of the left gastric artery. Subsequently, we successfully achieved hemostasis with coils using transcatheter arterial embolization.

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A 66-year-old female presented with fatigue, edema and jaundice. She had been diagnosed with Graves' disease at the age of 29 years but stopped going to the hospital for follow-up visits. Blood examination revealed pancytopenia and macrocytic anemia, and she was diagnosed with pernicious anemia due to low vitamin B12 level. Furthermore, she exhibited a high gastrin level, was positive for intrinsic factor antibodies, and showed atrophic changes predominantly in the fundic gland area of the stomach ; therefore, autoimmune gastritis was deemed to be the underlying cause. Symptoms were rapidly alleviated with vitamin B12 supplements. She was considered to have type 3B autoimmune polyendocrine syndrome on long-term follow-up. Among patients with autoimmune gastritis, there are high rates of gastric cancer and carcinoid complications. Therefore, in patients with autoimmune thyroid disease, care should be taken during endoscopic examination to observe for the presence of type A gastritis.

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An 80-year-old man was referred to our hospital for further examination and treatment of a gastric tumor that had been observed on upper gastrointestinal endoscopy at a neighboring hospital. Endoscopic examination of an elevated mass with focal ulceration on the upper gastric body and biopsy specimens revealed poorly differentiated adenocarcinoma. Computed tomography (CT) scan showed multiple mediastinal and intra-abdominal lymphadenopathies. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed on the enlarged intra-abdominal lymph nodes using a 21-gauge needle via the gastric wall and microscopic examination of the material obtained by EUS-FNA showed no evidence of metastatic adenocarcinoma. Immunohistological staining and flow cytometry led to the diagnosis of mantle cell lymphoma. The final diagnosis was stageIVA mantle cell lymphoma and synchronous gastric adenocarcinoma. R-CHOP chemotherapy was performed. Follow-up CT scan obtained one month later showed a decrease in the size of the lymphadenopathies. EUS-FNA of intra-abdominal lymphadenopathy is a promising diagnostic technique that can aid treatment decisions in patients with synchronous malignant lymphoma with primary gastric cancer.

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The patient was a 72-year-old woman who underwent contrast-enhanced computed tomography (CT) of the abdomen for worsening diabetes. A low-density area with a diameter of 20 mm was seen in the pancreatic body. With endoscopic retrograde cholangiopancreatography (ERCP), the pancreatic duct was found to be blocked in the tail and transitional sections. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed for a hypoechoic mass from the posterior wall of the central gastric body to the pancreatic body. Histological examination identified adenocarcinoma, and pancreatic cancer was diagnosed. Chemotherapy was administered, but the patient died on hospital day 335. With the consent of the family, autopsy was performed. The pancreatic body was found to be adhered to the posterior wall of the central gastric body. A flat, submucosal lesion measuring 16 × 15 mm was seen within the gastric wall of the adhesion site. The gross impression was that the pancreatic tumor and gastric tumor were connected. Histologically, both tissues represented moderately to highly differentiated tubular adenocarcinoma. Few reports have described needle tract seeding after EUS-FNA for pancreatic cancer. We have reported a case in which invasion was confirmed via the EUS-FNA puncture route.

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The patient was an 82-year-old man who had undergone pancreaticoduodenectomy (PD-IIA-2, D1) for intraductal papillary mucinous neoplasm in the pancreatic head in September 2013. Intraoperative findings were that the pancreas was soft without dilatation of the main pancreatic duct, and the postoperative course was uneventful including the absence of a pancreatic fistula.
In December 2013, he was admitted to our hospital because of acute cholangitis with disseminated intravascular coagulation (DIC). When he started to take foods orally after conservative treatment of DIC, the serum amylase level became elevated.
Abdominal CT and MRCP showed fluid collections within the jejunal wall and also dilatation of the remnant main pancreatic duct at the level of the pancreatojejunostomy. We considered that the both findings indicated anastomotic site occlusion. Although the site of anastomosis was difficult to identify, a single-balloon enteroscopy revealed a submucosal bleb consisting of the intramural fluid collection. After performing direct puncture at the submucosal bleb, the anastomotic stricture and the remnant pancreatic duct could be radiologically visualized with contrast injection. Then, the stricture was resolved with a balloon dilation following a needle knife incision. The serum amylase and the diameter of the remnant main pancreatic duct were normalized soon after the treatment. Single balloon enteroscopy enabled the anastomosis site to be endoscopically accessed even in a patient with surgically altered anatomy after pancreaticojejunostomy. Also, the anastomotic stricture could be resolved with the combination of incision and balloon dilatation.

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Nonexposed endoscopic wall-inversion surgery (NEWS) is a laparoscopy-assisted endoscopic full-thickness resection technique without transmural communication, which can theoretically avoid intra-abdominal contamination or iatrogenic tumor seeding on the peritoneum. It is applied to perorally retrievable protruded or intraluminal-type subepithelial tumors or possibly node-negative early gastric cancers that are difficult to resect by endoscopy. Furthermore, by combining it with sentinel node navigation surgery, the application can be expanded to possibly node-positive early gastric cancers as a less invasive, function-preserving surgery. The NEWS procedure has many new and challenging steps : placing accurate serosal markings, laparoscopic seromuscular incision and suturing, endoscopic mucosal incision around the inverted lesion, and submucosal incision close to the suture. Although many issues remain to be solved, NEWS is expected to become the ideal minimally invasive surgery for gastric neoplasms.

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The modified LA classification, including the minimum change (white mucosa and redness), is widely used to diagnose reflux esophagitis in Japan. One of the most important considerations in diagnosing an esophageal mucosal break is observing the lower esophagus, which is extended by inserting air into it after a deep inspiration. The diagnostic concordance rate for a mucosal break is high; however, the diagnostic concordance rate for a minimum change is low. This is the reason that there is neither a standardized evaluating system nor a definition of minimum change (obscure erythema, whitish mucosa). A standardized definition of minimum change should be determined in the near future.
Reflux esophagitis is caused by excessive esophageal exposure to acid. Therefore, in order to cure this disease, it is necessary to normalize excessive esophageal exposure to acid. In the guidelines for GERD by the Japanese Society of Gastroenterology, a standard-dose proton pump inhibitor (PPI) is recommended as the first-line therapy. The response rate to a standard dose of PPI among patients with mild reflux esophagitis is 90-95% and that among patients with severe reflux esophagitis is 80-85%. Should the standard dose of PPI not be effective, changing to another PPI and/or the method of administration (i.e., before a meal) might be effective.

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[in Japanese]

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