A 64-year-old man underwent upper gastrointestinal endoscopy for investigation of melena and anemia. Endoscopic examination showed an elevated lesion measuring about 4.0 cm in size which resembled a submucosal tumor in the lesser curvature of the upper stomach. There were some reddish depressions on the surface of the lesion and they showed an irregular micro-surface and vascular pattern. Endoscopic ultrasonography showed a low echoic tumor and the fourth layer under the tumor was thick. We considered that it was gastric cancer. However, several biopsies did not reveal any tumor. Endosonography-guided fine needle aspiration biopsy and mucosal cutting biopsy did not reveal a tumor. The patient desired surgery due to a high possibility that the tumor was cancerous and that it was the source of bleeding. Rapid histology during the surgery revealed an extremely well-differentiated adenocarcinoma infiltrating the subserosa. Total gastrectomy and dissection of D2 lymph nodes were performed. There was no metastasis to the lymph nodes. No recurrence has been seen at 27 months after the surgery.

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We encountered two cases of post-endoscopic sphincterotomy (EST) hemorrhage that was refractory to electrocoagulation using a sphincterotome, tamponade using a balloon, and spray/injection using epinephrine/ethanol, in which we finally achieved hemostasis by endoclip placement with the use of a forward-viewing endoscope. Although balloon tamponade, epinephrine/ethanol spray/injection, and electrocautery treatment have been reported as useful hemostatic techniques, hemoclip use has been limited for post-EST hemorrhage because of the technical difficulty of releasing the clips at the bleeding site when using a lateral-viewing endoscope. In the first case, we could easily place endoclips at the bleeding site on the post-EST papilla using a forward-viewing endoscope in the retroflexed position, while, in the second case, we could place endoclips using a forward-viewing endoscope in the straight position. There were no adverse events during or after the procedures. We could successfully obtain hemostasis by endoscopic clipping.
Although EST is widely accepted and commonly performed for patients with pancreatobiliary disorders, serious and refractory hemorrhage occasionally develops. Endoclip placement is one of the alternative hemostatic treatments that should be tried when post-EST bleeding proves refractory to conventional techniques such as balloon tamponade, epinephrine/ethanol spray/injection, and electrocautery treatment.

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A 78-year-old woman was diagnosed as having choledocholithiasis with benign common bile duct stricture by endoscopic retrograde cholangiopancreatography. We inserted three plastic stents in the common bile duct to dilate the biliary stricture. After 2 months, we retrieved all of the plastic stents and confirmed biliary dilatation. Simultaneously, endoscopic lithotomy was performed without any complications. Multiple plastic stents were safely used for the treatment of choledocholithiasis with benign common bile duct stricture.

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We report herein a 62-year-old male patient having pancreatic stones and a migrated pancreatic tube four years after undergoing pancreatoduodenectomy for intraductal papillary mucinous neoplasm of the pancreas head followed by modified Child's type reconstruction. The patient presented with epigastric pain. Imaging studies showed acute pancreatitis caused by pancreatic stones and a migrated pancreatic tube in the remnant pancreas. We performed endoscopic removal of the pancreatic stones as well as the migrated tube using a short-type double-balloon enteroscope (DBE) and a basket catheter. The DBE technique is one of the useful alternatives for the treatment of pancreatic diseases in patients with previous upper gastrointestinal surgery.

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We retrospectively analyzed the data of 12 consecutive patients treated with 18-mm-diameter Niti-S stents for obstructive colorectal cancer to determine the usefulness of these stents in colonic stenting as a bridge to surgery. The technical and clinical success rates were both 100%, and no procedure-related complications were noted. The technical and clinical success rates and rate of procedure-related complications using the 18-mm-diameter stent were not significantly different from those using the 22-mm-diameter stent in 21 cases in our hospital.
The Niti-S stent has good conformability. Intestinal tract burden is believed to be reduced with the 18-mm-diameter stent compared with the 22-mm-diameter stent because of low axial force, while usefulness was maintained.

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Background and Aim : Propofol has been suggested to be superior to benzodiazepines when used as a sedative agent for endoscopic examination. The aim of the present study was to systematically evaluate the safety and efficacy of propofol sedation for endoscopic submucosal dissection (ESD).
Methods : PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched in order to identify randomized trials eligible for inclusion in the systematic review. Data from the eligible studies were combined to calculate pooled odds ratios (OR) of developing restlessness, full awakening at 1 h post-ESD, hypoxia, and hypotension.
Results : We identified three randomized trials (298 patients) from the database search. Compared with traditional sedative agents, the pooled OR of restlessness and full awakening at 1 h post-ESD with propofol sedation were 0.41 (95% confidence interval [CI] : 0.21-0.81) and 8.59 (95% CI : 4.29-17.2), respectively, without significant heterogeneity. Compared with traditional sedative agents, the pooled OR of hypoxia and hypotension with propofol sedation were 1.13 (95% CI : 0.58-2.21) and 0.92 (95% CI : 0.25-3.41), respectively, indicating no significant differences between the groups.
Conclusion : Propofol sedation during ESD is more effective as compared with traditional sedative agent. The risk of complications is similar.

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