Biliary stricture is a common condition and it is necessary to differentiate between benign and malignant biliary strictures. Previous studies reported that approximately 3 to 17％ of patients undergoing surgery for suspected malignancy are found to have benign biliary stricture on postoperative pathological examination of resected specimens. Although most cases of benign stricture are primary sclerosing cholangitis (PSC), IgG4-related sclerosing cholangitis (IgG4-SC) and postoperative stricture, a few cases have secondary sclerosing cholangitis due to several reasons or non-specific cholangitis of unknown etiology. For accurate diagnosis and treatment, it is important to distinguish benign from malignant strictures and determine whether IgG4-SC is present or not. However, there are some difficult cases that have required surgery despite advanced imaging modalities and preoperative tissue samplings.

The Ⅰp＋Ⅱc type early colorectal cancer has a stalk and is accompanied by a depressed-type tumor in the head, but is different from the Ⅰp type lesion showing polypoid growth. We report clinicopathological features of Ⅰp＋Ⅱc type early colorectal cancer and its natural history. In this study, 22 cases (15 males, 7 females ; average age : 61.1 years old) of Ⅰp＋Ⅱc type early colorectal cancer, and two other Ⅰp＋Ⅱc type early colorectal cancer cases that were followed up, were examined. We performed clinicopathological comparison among the 22 Ⅰp＋Ⅱc type early colorectal cancers, 417 Ⅰp type early colorectal cancers and 147 depressed-type submucosal invasive (SM) colorectal cancers in this study, and examined the characteristics of these lesions. The tumor diameter of Ⅰp＋Ⅱc type early cancers was clearly smaller than that of the 417 Ⅰp type lesions (mean, 12.7mm vs. 16.3mm). The proportion of Ⅰp＋Ⅱc type early cancers that were located at the sigmoid colon [86.4％ (19/22 cases)] was significantly higher than those of Ⅰp type (64.7％) and depressed-type lesions (27.8％). The degree of cancer invasion of Ⅰp＋Ⅱc type early cancers was revealed as T1s [2(9.1％)], T1a [3(13.6％)], and T1b [17(77.3％)]. Lymph node metastases were identified in three (15％, 3/20) of the Ⅰp＋Ⅱc type SM cancers. These rates were significantly higher than the rates of SM invasion and lymph node metastasis among Ⅰp type lesions, and show malignant potential. However, there was no significant difference in the rate of lymph node metastasis between the Ⅰp＋Ⅱc type early cancers and the 147 depressed-type SM cancers. In one patient with Ⅰp＋Ⅱc type lesion who was followed for 22 months, the stalk disappeared, and the Ⅰp＋Ⅱc type lesion changed to Ⅰs＋Ⅱc type and then to Ⅱa＋Ⅱc type T1b cancer. The second case changed from Ⅰp＋Ⅱc to Ⅱa＋Ⅱc type T1b cancer over the course of 22 days. In conclusion, the Ⅰp＋Ⅱc type early colorectal cancer showed a specific growth pattern of depressed-type cancer that developed primarily at the sigmoid colon, and it showed the biological behavior of depressed-type colorectal cancers.

A 63-year-old male was admitted to our hospital for high fever and stomachache in November 2016. He had undergone distal gastrectomy and Roux-en-Y reconstruction in 2007. He was diagnosed with duodenal diverticulitis caused by an enterolith, and underwent endoscopic lithotomy with a thin colonoscope, PCF-PQ260L. He recovered and was discharged from the hospital on day 17. Five cases of duodenal diverticulitis with enterolith were reported in the Japanese literature, of which only two cases were treated with endoscopic therapy alone. This is the first report of endoscopic therapy for duodenal diverticulitis with Roux-en-Y reconstruction, and indicated that endoscopic therapy is useful for the treatment of duodenal diverticulitis caused by an enterolith.

A 41-year-old man was admitted to our hospital because of anorexia, malaise and fever. Endoscopic examination performed at our hospital showed diffuse white villi in the duodenum. Based on histopathologic examination of biopsy specimens obtained from the same site, he was diagnosed with Whipple’s disease. Treatment with antibiotics was started. Endoscopic images and histopathological images were evaluated at approximately 2 months and 8 months after diagnosis, and showed improvements over time. In most recent reports of this disease in Japan, Whipple’s disease was diagnosed based on observation of white villi in the duodenum, which is considered to be a very useful finding for the diagnosis of this disease. It is difficult to diagnose Whipple’s disease from the patient’s symptoms alone. Our patient had no background that would cause immune deficiency. This case is considered to be a valuable case in which we could confirm changes in the endoscopic images and pathological findings of Whipple’s disease over time.

The patient was a 74-year-old woman whose chief complaints were anemia and black stools. Abdominal contrast-enhanced computed tomography was performed to determine the cause of anemia, and localized jejunal wall thickening and surrounding lymph node enlargement were seen. On transoral double-balloon enteroscopy, ulceration was seen around the entire circumference of the jejunum. Ulcer margins were somewhat thick. The margin was regular and wall expansion was good. Blood vessels were exposed at the ulcer floor, and hemostasis was achieved by clipping. T-cell lymphoma was diagnosed from histopathological examination of a biopsy specimen. Enteropathy-associated T-cell lymphoma type Ⅱ was diagnosed from a specimen obtained from partial resection of the small bowel. This report describes a case of enteropathy-associated T-cell lymphoma diagnosed after intestinal bleeding.

HybridKnife^® (HK) is a novel device used in endoscopic submucosal dissection (ESD) for mucosal lifting by high-pressure water flow in combination with the ERBEJET 2 system. It can reduce the procedure time by reducing the need for supplemental fluid injections using an injection needle. It has not been clinically introduced in Japan ; hence, we evaluated its efficacy and safety with ERBEJET 2 in this clinical trial under authorization by the ethics committee of the University of Tsukuba Hospital.

We performed ESD using the HK-ESD system for gastric mucosal tumors between April 2014 and June 2015. The procedure time, number of device changes, and perforation or bleeding rate were compared with those in patients who underwent conventional ESD using Dual Knife, IT knife2, or SAFE Knife V (C-ESD) as a reference. One operator (T.N.) with extensive experience in conventional ESD performed all the procedures. He had experience in performing experimental ESD with HK in several porcine models.

HK-ESD was performed in 23 patients (16 men and 7 women, aged 55-85 years) with gastric adenoma (n=6) or carcinoma (n=17), and C-ESD was performed in 22 patients (20 men and 2 women, aged 53-83 years) with gastric adenoma (n=2) or carcinoma (n=20). Patient characteristics did not significantly differ between the two groups. Dissection speed did not significantly differ between the HK-ESD and C-ESD groups [23±11 mm²/min (mean±SD) vs. 19±12 mm²/min, p=0.303]. The number of device changes was significantly lower in the HK-ESD group than in the C-ESD group [1.0±0.9 (mean±SD) vs. 9.2±6.5, p＜0.001]. In one case in the HK-ESD group, a tiny perforation occurred and was treated with endoclip closure. Postoperative bleeding did not occur in the HK-ESD group, but 3 cases in the C-ESD group were treated with endoclip due to postoperative bleeding.

HK reduced the procedure time of gastric ESD owing to fewer instrument changes without major complications. HK with ERBEJET 2 may be efficient and safe for gastric ESD.

Guidelines for the management of antithrombotic agents during endoscopic procedures were published by the Japan Gastroenterological Endoscopy Society in July 2012. These guidelines have permitted continuation of antithrombotic agents during endoscopic treatment in patients with arteriosclerotic disease. However, there is no evidence on the safety of endoscopic submucosal dissection (ESD) in patients with gastric tumors receiving antithrombotic agents.

It is important to obtain an accurate grasp of the patient’s general condition by prior consultations with cardiologists and neurologists, manage bleeding during and after ESD by using the appropriate devices, perform preventative coagulation for all exposed vessels upon resected ulceration, and perform second look endoscopy in order to prevent complications related to ESD in patients taking antithrombotic agents.

We performed ESD for gastric tumors without interrupting low dose aspirin (LDA) at Hiroshima University Hospital since December 2010. We compared the 52 patients who underwent ESD for gastric tumors in which LDA was interrupted in the periendoscopic period between April 2005 and November 2010, and the 90 patients in which LDA was not interrupted between December 2010 and February 2017. There were no significant differences in the rate of bleeding after the procedure and the rate of poor bleeding control during the procedure between the LDA-continued group and the LDA-interrupted group. In the LDA-interrupted group, two patients suffered cerebrovascular infarction before ESD and two patients suffered acute myocardial infarction after ESD. No ischemic events occurred in the LDA-continued group during the perioperative period. Our data support continuation of routine LDA in patients undergoing gastric ESD.

Female physicians in training often need to take time off for maternity leave and/or child care during their residency and fellowship. A questionnaire on the education and training system including support structure for female trainee endoscopists was sent to 1,280 endoscopy instruction facilities accredited by the Japan Gastroenterological Endoscopy Society. Only 115 facilities filled out the questionnaire. Of these, 22 facilities (19％) have an education and training system that provides a support structure for female trainee endoscopists, takes into consideration that the female trainees may need to take time off for maternity leave and child care, and provides a smooth transition back to work after the leave period. The number of facilities with an education and training system that provides a support structure for female trainee endoscopists must be increased in Japan.

Objectives : Bleeding events related to endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are rare. However, for patients treated with antithrombotic agents, the bleeding risk of EUS-FNA is uncertain. Hence, the aim of this study was to assess the bleeding event rate associated with EUS-FNA in patients receiving antithrombotic treatment.

Methods : A retrospective study was conducted in 742 consecutive patients who underwent EUS-FNA for solid lesions between 2008 and 2015. We compared the bleeding event rates among patients who were not administered antithrombotic agents, those whose agent use was discontinued, those who continued treatment with aspirin or cilostazol, and those who were administered heparin as a replacement.

Results : There were 131 patients (17.7％) treated with antithrombotic agents. Seven experienced bleeding events, and the overall bleeding event rate was 0.9％ (7/742). All bleeding events were intraoperative ; there were no postoperative bleeding episodes. Subgroup analysis by antithrombotic agent revealed bleeding event rates of 1.0％ (6/611), 0％ (0/62), 1.6％ (1/61), and 0％ (0/8) for the non-administration, discontinuation of agents, continuation of aspirin or cilostazol, and heparin replacement groups, respectively. Only one severe bleeding event necessitated hemostatic treatment (1/742 ; 0.1％) ; this occurred in a patient in the nonadministration group, and there were no severe bleeding events in patients receiving antithrombotic treatment.

Conclusions : The present study found a low incidence of EUS-FNA-related bleeding in patients receiving antithrombotic treatment. The bleeding event rate was low even in patients who underwent EUS-FNA while continuing aspirin or cilostazol.