Endoscopic resection (ER), especially endoscopic submucosal dissection (ESD), is a therapeutic technique as well as simultaneously an important diagnostic technique as total excisional biopsy. Histopathological complete resection of colorectal carcinoma (CRC) with negative horizontal and vertical margins is indispensable for curative resection. Currently, among the factors associated with curative resection based on the Japanese Society for Cancer of the Colon and Rectum (JSCCR) Guidelines 2014 for the Treatment of CRC, only the submucosal invasion depth of CRC can be diagnosed before ESD. Endoscopic ultrasonography is a useful modality for diagnosing resectable submucosal layer with negative vertical cut end directly. Even in patients with submucosal deep invasive (T1b) CRCs, the risk of lymph node metastasis is minimal under certain conditions. It was reported that the incidence of lymph node metastasis was only 1.3% when T1 (SM) CRCs met three of the JSCCR Guidelines 2014 criteria (i.e., all but invasion <1,000 μm). In addition, ER of T1 (SM) CRC did not worsen surgical and oncologic outcomes in cases that required subsequent surgery. Lymph node metastasis occurred in some patients with T1b CRC even if they had undergone surgical operation. In patients who have undergone radical ER of T1 (SM) CRC, physicians should consider whether additional surgical resection is necessary or not. Thus, even for T1b CRCs, ESD as total excisional biopsy can be suitable if complete en bloc resection is achieved. In the near future, it may be possible to identify T1 (SM) CRCs that can be cured with only ESD using some molecular pathologic markers, instead of conventional hematoxylin-eosin specimens.

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A 57-year-old woman was endoscopically diagnosed with having a neuroendocrine tumor (NET) in the greater curvature of the middle gastric body. The tumor was single and was accompanied by ordinary atrophic gastritis. Serological examination showed anti-gastric parietal cell antibodies, and intrinsic factor antibodies were negative. We thought that the tumor was not typeINET, but the serum gastrin level was high at 740pg/ml. After laparoscopy and endoscopy cooperative surgery, pathological examination of the resected specimens revealed NET G2 (Ki-67 6.4%). Although enterochromaffin-like (ECL) cell hyperplasia was observed in the mucosa around the tumor, it did not progress to the endocrine cell micronests. The tumor was negative for gastrin staining. After Helicobacter pylori eradication therapy, her serum gastrin level decreased. As such ECL cell hyperplasia would occur by hypergastrinemia due to H. pylori infection, her final diagnosis was type III NET. This case was considered important in the differential diagnosis and treatment selection of NET.

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We report the endoscopic and histopathological findings of a case of autoimmune gastritis with multiple polyp-like nodules in the lesser curvature, anterior wall, and posterior wall of the gastric body. The patient was a 41-year-old woman who was incidentally found to have multiple polyp-like, elevated lesions in the stomach during the annual medical check-up. Laboratory examination revealed iron deficiency anemia and marked hypergastrinemia. On endoscopic examination of the stomach, whereas the antral mucosa was well preserved, the fundic mucosa was markedly atrophic, and the remaining non-atrophic mucosa was seen as multiple, island-like, elevated areas. On histopathological examination of the biopsied gastric mucosa, chief cells and parietal cells were nearly absent in the atrophic areas. In the remaining non-atrophic areas of the fundic mucosa, lymphocytic infiltration in the lamina propria was prominent, and many lymphocytes were found to have surrounded and destroyed the oxyntic glands. The description of endoscopic findings of multiple protuberances in the lesser curvature, in which active lymphocytic infiltration was prominent around the oxyntic glands, has been reported only rarely.

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We report a case of postoperative pancreatic fistula after pancreaticoduodenectomy that was successfully treated with endoscopic ultrasound-guided transgastric drainage. A 74-year-old man with intraductal papillary-mucinous carcinoma of the head of the pancreas underwent subtotal stomach-preserving pancreaticoduodenectomy. On postoperative day 14, based on fever and high WBC count, we suspected postoperative pancreatic fistula. CT scan revealed abdominal fluid collection behind the pancreatojejunostomy. As percutaneous drainage was abandoned due to the presence of the bowel between the abdominal wall and the lesion, endoscopic ultrasound (EUS)-guided transgastric drainage was attempted. After the procedure, drain fluid appeared but decreased gradually, and we could extubate the drain tube after one week. The patient was discharged from the hospital on postoperative day 34. Since EUS-guided transgastric drainage for postoperative pancreatic fistula after pancreatectomy appears to be minimally invasive and is expected to shorten the patient's hospitalization, it is an option for selected patients.

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Enteral stent placement for malignant enteral obstruction has become a safe and convenient procedure. Therefore, it has become possible to manage complicated cases of stenosis by enteral stent placement. The opportunity to manage malignant enteral obstruction at multiple sites by stent placement is increasing due to the extension of life expectancy of advanced cancer patients. In case of malignant enteral obstruction at multiple sites, it should not be attempted to treat all stenotic sites at one time because evaluation of stenosis at deeper sites tends to be insufficient. When long stenosis is treated by stent placement, the enteral stents should be delivered tandemly from the deeper end to the near end. In this case, more attention is required so that the guidewire does not fall out during the procedure. In addition, a stent with weak axial force should be chosen when an additional stent is deployed by stent-in-stent fashion at the bending site of the gastrointestinal tract. Because enteral stent placement for malignant enteral obstruction at multiple sites is a difficult procedure, endoscopists should be knowledgeable about not only the properties of the various stents themselves and the ordinary enteral stent procedure, but also the particular cautionary points of enteral stenting for malignant enteral obstruction at multiple sites.

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Multiple metallic stent deployment to malignant hilar biliary strictures is not a mere technique to deploy metallic stents into the right and left hepatic ducts. This technique is technically demanding because it involves insertion of various devices repeatedly to selected branches with a lateral view endoscope. Consequently, the functional liver volume is secured as much as possible. Since inappropriate stent deployment may induce intractable cholangitis in patients with malignant hilar biliary strictures, we must pay attention to the anatomy of the biliary tree on the hilar plate and must be familiar with the available devices. Otherwise, the prognosis of these patients is ominous. To conduct multiple metallic stent deployment successfully, it is important to develop a strategy based on these facts.

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Background and Aim : In Japan, after the revision of the gastrointestinal endoscopic guidelines for patients taking antithrombotics, endoscopic biopsies were permitted while continuing antithrombotic treatment. However, the risk of bleeding after the biopsy with or without cessation of antithrombotics has not been fully evaluated because bleeding events are very rare. The aim of this prospective study was to evaluate the risk for bleeding after upper gastrointestinal biopsy without cessation of antithrombotics.
Methods : Consecutive patients who underwent upper gastrointestinal endoscopic biopsy from December 2011 to March 2014 were enrolled in this study. Antithrombotic medication and its cessation status was checked at enrollment. To confirm bleeding events associated with biopsy, medical examination at the hospital or direct confirmation by telephone was done within 1 month after the biopsy.
Results : Among the 3758 patients who underwent endoscopic biopsies, 394 patients (10.5%) were medicated with antithrombotics, and 286 of them (72.6% of the total antithrombotics users) did not undergo cessation. Bleeding after the biopsy occurred in six cases (0.15%, 95% CI ; 0.09%∼0.22%), but there was only one case that had continued taking antithrombotics. The incidence of bleeding after biopsy was not significantly higher in the patients who had continued taking antithrombotics compared with the others (0.35% vs 0.14%, P = 0.38).
Conclusion : This prospective study showed that continuation of antithrombotics did not increase the bleeding risk after upper gastrointestinal endoscopic biopsy.

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