For further improvement of colorectal cancer (CRC) screening in Japan, consideration should be given to more efficient use of colonoscopy in population-based screening. The effectiveness and safety of screening colonoscopy should be clarified first. Regarding its effectiveness, reduced CRC mortality with sigmoidoscopy has been proven in several randomized controlled trials (RCTs), whereas several RCTs on total colonoscopy are currently ongoing. In addition, the cost-effectiveness of and nationwide capacity for performing colonoscopy screening should be evaluated. Model analysis has been used to assess the cost-effectiveness of and nationwide capacity for performing colonoscopies in CRC screening in several foreign countries. Our recent study applying model analysis for the assessment of CRC screening in Japan indicates that the use of screening colonoscopy could help improve both the effectiveness and cost-effectiveness of screening. Introduction of screening colonoscopy presents a potentially strong option in Japan. Despite this promise, the large number of requisite colonoscopies may pose a problem. Further investigation, including evaluation of the capacity to perform screening colonoscopies, is necessary for assessing the appropriateness of screening colonoscopy in Japan.

The association between esophageal squamous cell carcinoma and esophageal achalasia has been well known. However, almost all cases of esophageal carcinoma are in the advanced stage when they are detected. We herein report a case of coexisting superficial esophageal carcinoma with esophageal achalasia and successful treatment with minimally invasive surgical modalities. A 74-year-old woman was referred for the treatment of superficial carcinoma of the esophagus associated with esophageal achalasia. She has been suffering from achalasia for the past 20 years. Periodic endoscopic examination detected slightly depressed irregular mucosa in the upper thoracic esophagus, and histopathological examination of biopsy specimens revealed squamous cell carcinoma. Magnified narrow band imaging during endoscopic examination showed irregular intra-epithelial capillary loops in the lesion and we diagnosed the depth of tumor invasion as T1a-LPM. Esophageal achalasia was diagnosed as the sigmoid type and the maximum diameter of the esophagus was 4.5 cm as observed on barium swallow. We first performed endoscopic submucosal dissection (ESD) of the superficial esophageal carcinoma. Histopathological findings of the resected specimen revealed squamous cell carcinoma and the tumor invaded the lamina propria mucosa (LPM) without any vascular invasion. Four months later, we performed laparoscopic surgery for esophageal achalasia. She is well and alive without tumor recurrence and without any symptoms related to esophageal achalasia.

The patient is an 81-year-old female. Several months previously, she was examined due to continuing pains in the front of the chest. Three years prior to this, 10mm large hyperplastic polyps were observed at two locations in her stomach, but they were not recognized to have malignant potential. After careful examination this time, the same lesions were found to have increased to 30mm in size, and biopsy examination revealed adenocarcinoma. In the CT scan of the patient’s chest, it was found that she had an upside-down stomach, since the entire stomach had deviated from inside the mediastinum. Based on the diagnosis of early gastric cancer accompanied by an upside-down stomach, we decided to perform open surgery. The hernial orifice was opened to a size of 8cm, through which the stomach was pulled, and the hernial orifice was then plicated. Distal gastrectomy with D1 lymphadenectomy was then performed. This case exhibited not only the rare and unique condition of an upside-down stomach but also the rare phenomenon of hyperplastic polyps becoming cancerous. This rare case is presented along with a review of the relevant literature.

A 56-year-old man who had been diagnosed with an endocrine tumor near the duodenal papilla on screening upper gastrointestinal endoscopy, was admitted to our hospital. As the tumor was adjacent to the papilla of Vater, pylorus-preserving pancreatoduodenectomy was performed. The pathological findings of the specimen that had been resected from the vicinity of the papilla of Vater, identified a 4-mm tumor in the descending portion of the duodenum, which had been diagnosed preoperatively by endoscopy as a neuroendocrine tumor. An additional neuroendocrine tumor with a diameter of 3 mm was found in the boundary region of the Ab portion of the papilla and Bi portion of the lower bile duct. The patient is alive without recurrence more than 6 years and 7 months after the surgery.

A 73-year-old woman visited our hospital because of general malaise and anemia. Gastrointestinal endoscopy and colonoscopy revealed irregularly shaped huge ulcers in the gastric body, antrum and duodenum. Computed tomography showed wall thickening of the stomach, duodenum and the proximal part of the jejunum. Pathological diagnosis of the biopsy specimens was enteropathy-associated T-cell lymphoma (EATL) type Ⅱ. She was admitted because of dyspnea due to acute pulmonary thromboembolism. Fourteen days after admission, she died from peritonitis due to perforation of the ileum. EATL, a rare disease, is a subtype of mature T cell and NK cell tumor, mainly located in the small intestine. We report a much rarer case of EATL located in the stomach and duodenum.

The purpose of this study was to investigate the endoscopic features of lanthanum deposition in the gastrointestinal mucosa. We retrospectively reviewed the endoscopic images of 10 patients who had received a histological diagnosis of lanthanum deposition in the gastroduodenal mucosa. The patients were 9 men and 1 woman with an average age of 64.3 years （range: 42 to 77 years）. All patients were undergoing hemodialysis for chronic renal failure, and had been receiving lanthanum carbonate for 12 to 86 months. All patients had lanthanum deposition in the stomach, which presented as white lesions. Magnifying endoscopic observation, which was performed in six patients, also demonstrated the deposition of white microgranules. Three patients had lanthanum deposition in the duodenum, which manifested as white duodenal mucosa. In conclusion, lanthanum deposition in the gastroduodenal mucosa typically manifests as white lesions. Endoscopists should suspect lanthanum deposition when they detect white lesions in the gastroduodenal mucosa of patients who are taking lanthanum carbonate.

It is desirable to perform prophylactic clipping in patients who are at high risk for bleeding after endoscopic mucosal resection (EMR). Quick Clip Pro^® (OLYMPUS), ZEOCLIP^® (ZEON MEDICAL), and Resolution^® (Boston Scientific Japan) offer precise rotation with open and close functionality for exact clip placement. A medium-sized mucosal defect can be closed with sequential clips as if zipping up. It is difficult to achieve complete closure of a large mucosal defect using only conventional clips. Several useful methods have been reported such as the “hold-and-drag” closure technique, endoscopic purse-string suture, slip knot clip suturing method, string clip suturing method, “loop clip” closure technique, and mucosal incision method. Extensive endoscopic knowledge of suture methods is required to manage complications endoscopically.

Background and Aim : To compare the usefulness of the self-expanding metallic stent (SEMS) with that of the transanal drainage tube (TDT) and emergency surgery after failure of decompression (ESFD) in patients with malignant colonic obstruction (MCO), and to evaluate post-decompression histopathological changes.

Methods : From January 2010 to June 2015, 39 patients with MCO received SEMS, TDT, and ESFD. We evaluated the outcomes including success rates of placement, clinical outcomes after decompression, and histopathological findings of the resected specimens.

Results : Technical success rates were 100％ for SEMS and 78.9％ for TDT. Clinical success rates were 100％ for SEMS and 80.0％ for TDT. Postoperative ileus was significantly less frequent after SEMS than after TDT (P = 0.014). Histopathological edema grade was significantly lower for SEMS than for TDT and ESFD (P ＜ 0.0001). There was no significant difference between edema grade and duration of decompression in the TDT group (P = 0.629), whereas all patients with SEMS were classified in a low edema grade (grade 0-2). Rate of stoma creation was significantly higher in patients with a high edema grade (grade 3) than in those with a low edema grade (grade 0-2) (P = 0.003). There was no microscopic perforation in any group.

Conclusion : Significantly greater resolution of histopathological edema was achieved after placement of SEMS than after placement of TDT. These findings provide an indication of favorable clinical outcomes of SEMS in comparison with TDT and ESFD.