The clinical approach for gastric submucosal tumors (SMTs) of 2 cm or less in diameter is discussed by reviewing previous reports. In the case of gastrointestinal stromal tumor (GIST) among SMTs, even if it is 2 cm or less in diameter, although rare, it may rapidly enlarge in size and will likely become malignant, and therefore it is necessary to remove it through a method such as laparoscopic and endoscopy cooperative surgery (LECS). Generally, under esophagogastroduodenoscopy (EGD), if an SMT is found to be stiff by touching with forceps, there is a high possibility that it is a gastrointestinal mesenchymal tumor (GIMT), and it would be necessary to follow the tumor once or twice a year according to the guidelines. The diagnosis of GIMT can be made by endoscopic ultrasound (EUS), and therefore it is recommended that EUS be performed at least once. However, EUS-fine needle aspiration (EUS-FNA) should be performed in cases where uneven internal echo, border irregularity, cystic degeneration, high-echo spot, and other findings suspicious of GIST are found on EUS, or in cases where surgical indication should be judged due to an increase in size to more than 2 cm during follow-up.

Background/objectives : Clip plication is often performed as a conventional procedure after endoscopic resection of colorectal polyps. The postoperative bleeding rates, treatment times, and costs with or without clip plication were investigated. Methods : The subjects were 174 patients (332 lesions) undergoing clip plication after endoscopic resection between February 2012 and January 2013 (the clip group) and 210 patients (434 lesions) who did not receive clip plication with endoscopic resection performed between February 2013 and January 2014 (the non-clip group). Patient background (age, sex, underlying disease, and whether oral antithrombotic drugs were taken), characteristics of the resected polyps (number of polyps per patient, size, site, macroscopic type, and tissue), postoperative bleeding rates, and time required for polyp resection were compared between the two groups. Furthermore, the numbers of clips required for plication were studied in the clip group. Results : There were no differences in background factors or postoperative bleeding rates between the non-clip group and clip group (postoperative bleeding rate, 1.4％ vs. 1.7％), while the resection time was significantly shorter in the non-clip group than in the clip group (145 [median ; range, 46-2,443] seconds vs. 257 [91-1,789] seconds) (p<0.01). The median number of clips required for plication was 2 (1-6) and the cost per clip was JPY 1,950. Conclusion : Clip plication after resection is not necessary as a routine procedure for prevention of bleeding after endoscopic resection of colorectal polyps, and shortening of treatment time and cost reduction can be realized by its omission.

An 18-year-old man was referred to our department because of diarrhea and weight loss. His medical history was significant for anhidrosis at the age of 3 months. He presented with hypodontia, sparse hair, and hypoplastic sweat glands. Colonoscopy was performed. Because ulcerative colitis was suspected, he was treated with mesalazine and prednisolone. A second colonoscopy was performed nine months after the initial diagnosis because of relapse of colitis, which revealed longitudinal ulcers in the sigmoid and ascending colon. The diagnosis of Crohn’s disease was made. He was treated with infliximab(IFX) and 6-mercaptopurine(6-MP), which provided symptom resolution. Since clinical signs of anhidrotic ectodermal dysplasia were noted, anhidrotic ectodermal dysplasia with immunodeficiency (EDA-ID) was highly suspected. EDA-ID is caused by mutations in the gene encoding nuclear factor-κB essential modulator protein (NEMO). Inflammatory colitis in patients with EDA-ID is hence called NEMO colitis and is a rare condition. Here we report a case of this rare pathological entity.

A 57-year-old female underwent colonoscopy for follow-up after resection of a rectal carcinoid tumor. A submucosal tumor of 1.5 cm in diameter was detected at the ascending colon. The tumor had a few small depressions on the mucosa. Endoscopic ultrasound revealed a low echoic tumor including high echoic parts. She underwent laparoscopic-assisted ascending colectomy. Microscopically, the tumor consisted of necrotic tissue including an Anisakis body and granulomatous tissue. After the histological diagnosis was made, her serum was found to be positive for the antibody to Anisakis. This tumor was found incidentally and caused no symptoms. Anisakiasis is usually an infection of the stomach and most patients have severe acute abdominal symptoms. We experienced silent anisakiasis of the ascending colon.

A 48-year-old woman was admitted to our hospital with epigastric pain with elevated serum liver enzymes and a dilated common bile duct. An abdominal CT scan showed that the intrahepatic and common bile ducts were dilated. T1-weighted MRI of the pancreas showed low signal intensity, whereas T2-weighted MRI of the pancreas showed high-signal-intensity spots in the pancreatic head. Overall, the branches of the pancreatic duct appeared to be dilated. Endoscopic ultrasonography showed that the common bile duct was 10 mm in diameter, and that the lower bile duct was compressed by the low-echoic mass located in the pancreatic head. These findings suggested that a tumor, located at the orifice of the papilla of Vater, had prolapsed and expanded into the main pancreatic duct up to the central portion of the pancreas. Endoscopic biopsy of the tumor thrombus in the main pancreatic duct showed that the tumor was a neuroendocrine tumor. Total pancreatectomy was performed. The pathological diagnosis was non-functional neuroendocrine tumor G2. We report here a rare case of intraductal growth of a pancreatic neuroendocrine tumor, which could be diagnosed preoperatively.

An 82-year-old female was admitted with right hypochondriac pain. Clinical findings, blood examination and computed tomography revealed that she had acute cholangitis. She underwent endoscopic retrograde cholangiopancreatography （ERCP） for biliary drainage. The major papilla was located at the inside of a diverticulum on the right side, and it was difficult to maintain an appropriate view of the papilla through the duodenoscope. Exchanging the duodenoscope with a forward-viewing endoscope enabled insertion of a plastic stent in the pancreatic duct and it made the papilla face outside of the diverticulum, allowing completion of biliary drainage. In our case, all procedures were feasible without highly invasive treatment and without special instruments including a sphincterotome. Exchange to a forward-viewing endoscope can be prioritized as an effective method in patients with parapapillary diverticulum.

The Takase method of endoscopic injection sclerotherapy (EIS) obliterates the esophagogastric varices and their associated blood supply. Obliteration of blood supply routes reduces the recurrence rate of esophageal varices after EIS.　In endoscopic injection sclerotherapy with simultaneous ligation (EISL), EIS is performed first followed by endoscopic variceal ligation (EVL). Suction of the injection site is maintained after EIS to facilitate EVL. Band ligation is performed at the site of injection. As the blood flow is blocked by ligation, EISL allows the sclerosant to remain at the site. It is less invasive and requires fewer sessions and less sclerosant than the regular EIS procedure. There is less chance of bleeding from the injection site as the variceal puncture site is ligated. EISL is indicated for esophageal varices, especially pipe line varices, cardiac varices that drain to esophageal varices, and special types of varices.

Background and Aim : Endoscopic balloon dilation (EBD) is an alternative to surgery for small bowel strictures of patients with Crohn’s disease (CD). However, little is known about the long-term efficacy of EBD. The aim of the present study was to clarify the long-term outcome of EBD for small bowel strictures in patients with CD.

Methods : Subjects comprised 65 patients with CD who underwent EBD for small intestinal strictures and were followed up for at least 6 months. All subjects had obstructive symptoms as a result of small bowel strictures. Short-term success was defined as technical success and the disappearance of obstructive symptoms. The short-term success rate of EBD, its safety profile, the cumulative surgery-free rate and the cumulative redilation-free rate were investigated.

Results : Short-term success rate was 80.0％ (52/65). Complications were encountered in six of the 65 patients (9.2％). Seventeen patients (26.2％) underwent surgery during the observation period of this study. Cumulative surgery-free rate after initial EBD was 79％ at 2 years and 73％ at 3 years, respectively. EBD successful cases showed significantly higher surgery-free rates than unsuccessful cases (P < 0.0001). In 52 of the successful cases, the cumulative redilation-free rate after initial EBD was 64％ at 2 years and 47％ at 3 years, respectively.

Conclusion : EBD for small bowel strictures secondary to CD provides not only short-term success but also long-term efficacy. However, the high redilation rate is one of the clinical problems of this procedure.