Endoscopic retrograde cholangiopancreatography (ERCP) is indicated for many conditions that affect the liver, gallbladder, bile ducts and pancreas. ERCP requires sophisticated skills, and post-ERCP pancreatitis remains a significant complication that occurs in association with this procedure. There are many different treatment guidelines for post-ERCP pancreatitis ; thus, deciding the appropriate treatment can be difficult. Clinical practice guidelines for this morbidity have been awaited. We have therefore established and published clinical practice guidelines for the treatment of post-ERCP pancreatitis. This paper provides an outline of these guidelines.

A 66-year-old woman had a 10mm size, undifferentiated-type, early gastric cancer in the angle of the stomach. Endoscopic submucosal dissection was performed, and the cancer was completely resected pathologically by the therapy. However, it recurred in multiple lymph nodes four years and two months later. Recently, there have been several reports of recurrence among patients who had undergone endoscopic therapy for undifferentiated-type early gastric cancer on long-term observation. It is unclear whether endoscopic submucosal dissection is the best therapy for undifferentiated-type early gastric cancer. This is currently being studied in a multicenter prospective trial in Japan and the results of the trial are awaited.

A 73-year-old woman was referred to our hospital with an enlarging gastric submucosal tumor (SMT) in the gastric body on the lesser curvature side with the diagnosis of lipoma. Follow-up esophagogastroduodenoscopy detected a well differentiated adenocarcinoma of 0-Ⅱc type in the mucosa just above the lipoma, which had increased in size. For the simultaneous treatment of early gastric cancer and lipoma, we devised the endoscopic unroofing method using circumferential incision. The endoscopic unroofing method using circumferential incision was useful in the treatment of early gastric cancer and reduction of the lipoma. This endoscopic procedure resulted in relatively easy curative resection of the mucosal cancer just above the lipoma. We report its details along with a review of the related literature.

A 27-year-old man with melena visited a local physician. Bleeding scintigraphy showed a hot spot in the distal ileum, and he was referred to our hospital to inspect the small intestine in more detail. First, we performed ^99mTc-scintigraphy ; however, there was no positive signal of Meckel’s diverticulum. Then, double-balloon endoscopy revealed a pedunculated polyp that was similar to an upheaval lesion of approximately 50mm in size with an ulcer on the top. The polyp was located 40cm on the oral side from Bauhin’s valve. Although we had planned to resect this polyp endoscopically, histological examination of biopsy specimens from the top of the polyp revealed ectopic gastric mucosa. Therefore, the diagnosis was changed from an ileal polyp to inverted Meckel’s diverticulum, and laparoscopic ileal segmental resection was performed. The resected specimen exhibited an ectopic gastric gland and pancreatic tissue. Endoscopic resection of inverted Meckel’s diverticulum is associated with complications such as gastrointestinal perforation and should be avoided. It is important to be able to recognize the characteristic endoscopic image of inverted Meckel’s diverticulum.

Introduction : Treatment with chemoradiotherapy is recommended for locally advanced, unresectable pancreatic cancer. Intensity-modulated radiation therapy (IMRT) for dose concentration-enhancement with placement of a gold marker to determine the three-dimensional radiation field, is available at some hospitals. We evaluated the efficacy of radiation treatment with IMRT after gold marker placement for pancreatic cancer using endoscopic ultrasound (EUS)-guided fine needle aspiration (EUS-FNA).

Methods : Six patients with stage Ⅰ-stage ⅣA pancreatic cancer were treated with IMRT after gold marker placement using EUS-FNA procedures in our hospital from December 2013 to December 2014.

Results : The gold marker was placed successfully in all six patients. No serious adverse events were observed. In addition, the treatment was completed without the gold marker falling off during IMRT. The treatment effect was stable disease in five patients and progressive disease in one patient. In the five patients with stable disease, FDG uptake was decreased on positron emission tomography/computed tomography. At one year after the end of treatment, four patients were still alive.

Conclusion : IMRT with gold marker placement, which is an application of the EUS-FNA technique, is beneficial for the treatment of pancreatic cancer. Our experience is limited to a few cases thus far, but we have confirmed that the procedure is safe and expect to apply it in the clinical setting.

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is a new method of gallbladder drainage in patients with acute cholecystitis. EUS-GBD has as high a success rate as percutaneous drainage and can be used to perform internal drainage similar to transpapillary drainage. Methods of EUS-GBD procedures have not been well discussed due to its short history and lack of sufficient level of evidence. When cholecystitis occurs, the gallbladder lumen becomes so large that the gallbladder is easily punctured. On the other hand, insertion of devices such as a dilator, stent, or naso-cystic tube into the gallbladder is often difficult compared to other interventional EUS procedures, because the gallbladder is not adhered to the stomach or duodenum unlike walled-off necrosis, and is not fixed in an organ unlike intrahepatic bile ducts and pancreatic ducts. Moreover, the fact that the location and orientation of the gallbladder are not fixed makes the procedure difficult, and many tips and tricks are required to perform EUS-GBD safely and effectively. In this commentary on technical tips of EUS-GBD, we describe our technique of EUS-GBD using a plastic stent and a naso-cystic tube.

Background and Aim : Endoscopy, barium esophagram and manometry are used in the diagnosis of achalasia. In the case of early achalasia, characteristic endoscopic findings are difficult to recognize. As a result, the diagnosis of achalasia is often made several years after symptom onset. Therefore, we examined the endoscopic findings of the cardiac orifice in achalasia and propose a new classification.

Methods : A total of 400 patients with spastic esophageal motility disorders who underwent peroral endoscopic myotomy (POEM) at our hospital between March 2014 and August 2015 were screened for this study. Champagne glass sign (CG) was defined as when the distal end of the lower esophageal sphincter relaxation failure (LESRF) was proximal to the squamocolumnar junction (SCJ) and the SCJ was dilated in the retroflex view. Specifically, CG-1 was defined as a distance from the SCJ to the lower end of LESRF of ＜1 cm, and CG-2 was defined as a distance ≥1 cm.

Results : CG-0 was seen in 73 patients (28.0％), whereas the CG sign was seen in 186 patients (71.3％), of whom 170 (65.1％) were CG-1 and 16 (6.1％) were CG-2.

Conclusions : The CG sign is often observed in esophageal achalasia patients. CG-0 (equal to Maki-tsuki) was observed in 28.0％ of achalasia patients only. Its absence with dilated SCJ cannot be used to rule out achalasia. Barium esophagram and manometry should be done if esophageal achalasia is strongly suspected.