Early gastric cancer discovered after Helicobacter pylori eradication therapy (EGCAE) is generated from gastric mucosa that had been infected with H. pylori, and was subsequently modified by the eradication therapy. A reddish depressed lesion is a typical endoscopic feature of differentiated type EGCAE. Histological examination reveals epithelium with low-grade atypia that covers the tumor tissue. Consequently, it is difficult to detect EGCAE endoscopically, and some lesions are discovered later as cancers with submucosal invasion. It is important for endoscopists to be able to recognize EGCAE so that treatments can be administered at the early stage of cancer. Endoscopists should be aware of the characteristic features of EGCAE.

[Background] Double needle fixation devices have generally been used in percutaneous endoscopic gastrostomy (PEG). In some cases, however, it is difficult to fix the stomach to the abdominal wall by this double needle fixation device due to limited available space, while a single needle fixation device can easily fix the stomach even in such cases. In this study, we investigated the safety and usefulness of a single needle fixation device in comparison with a double needle fixation device.

[Materials and Methods] In the first fundamental experiment, a T-fastener and double needle fixation device were fixed to a metal plate followed by traction with a force of 1N (kg・m/s²), and the slack was measured as time elapsed. The second fundamental experiment was to test the durability of the devices, in which strings fixed to the pig stomach by both fixation devices were continuously pulled with increasing force. In a clinical trial, both fixation devices were used during PEG in the same patient, and the fixation time and slack as time elapsed were measured. In another clinical trial, PEG with three-point fixations was performed with a single needle or double needle fixation device, and the operation time and adverse effects were prospectively evaluated.

[Results] In the first fundamental experiment, there was no remarkable slack as time elapsed with both fixation devices. There was no difference in durability between the single needle and double needle fixation devices, and there was no damage in the pig stomach with either device. In the first clinical trial, the fixation time of the single needle fixation device was shorter than that of the double needle fixation device, and there was no remarkable slack as time elapsed with either device. Furthermore, there were no complications associated with PEG using either fixation device.

[Conclusion] The single needle fixation device seems to be a feasible device for conventional use during PEG.

An 88-year-old woman was treated with prednisolone (PSL) for bullous pemphigoid in the department of dermatology of our hospital. Her skin symptom was exacerbated when the PSL dosage was tapered, and she was referred to our department to examine whether she had a gastrointestinal tumor. Esophagogastroduodenoscopy (EGD) revealed a protruded lesion in the anterior wall of the lesser curvature of the antrum. Examination of biopsy specimens of the lesion showed adenoma, but endoscopic submucosal dissection (ESD) was performed because this lesion was strongly suspected as being early gastric cancer based on the endoscopic findings. ESD resulted in endoscopic curative resection of early gastric cancer as confirmed by pathological examination. The dose of PSL could be tapered smoothly after ESD. Therefore, ESD of early gastric cancer was thought to be an effective treatment in this case.

Case 1 was a 64-year-old man who suffered from choledochoduodenal fistula (CDF) after endoscopic placement of a self-expandable metallic stent (SEMS) for biliary tract obstruction caused by advanced duodenal cancer Stage Ⅳ (T4, N3, M1). Case 2 was a 68-year-old man who suffered from CDF similar to case 1 after endoscopic placement of a SEMS for biliary tract obstruction caused by advanced pancreatic head cancer cStage Ⅳb (T3N2M1). Thereafter, the two patients developed duodenal stenosis of the superior duodenal angle or the second portion, respectively, by tumor invasion. We performed endoscopic duodenal SEMS placement in these 2 cases. These procedures were successful and we could assure safety without short- and long-term occurrences of accidental symptoms. It is important to select a treatment procedure appropriate for the general state and prognosis of the patient and an optimal duodenal stent.

A 38-year-old man with a preceding 3- to 4-year history of increased frequency of bowel movements and bloody stools presented at our hospital complaining of persistent abdominal pain. Upper gastrointestinal endoscopy revealed an ulcerative colitis (UC)-like lesion in the stomach and duodenum, while lower gastrointestinal endoscopy revealed UC of the entire colon. Further examination by computed tomography revealed pancreatic enlargement. Examination of biopsy specimens from the pancreas obtained by endoscopic ultrasound fine needle aspiration (EUS-FNA) revealed granulocytic epithelial lesions, leading to the diagnosis of type 2 autoimmune pancreatitis (AIP). UC and AIP were managed by the administration of prednisolone and 5-ASA preparations, after which the lesions resolved. The patient was placed on 5-ASA maintenance therapy and there has been no recurrence. To our knowledge, this is the first report of UC concurrently occurring with upper gastrointestinal lesions and type 2 AIP.

A 65-year-old female was admitted for endoscopic retrograde cholangiopancreatography (ERCP) examination because her private doctor found abnormal dilatation of her pancreatic duct during abdominal ultrasound examination. ERCP showed that the pancreatic duct was smooth and regular but had a significant bend at the neck of the pancreas. Although a single pig-tailed plastic stent was inserted into the main pancreatic duct to prevent ERCP pancreatitis, the patient presented to the emergency room 17 days after ERCP for severe abdominal pain and hypotension. Laboratory blood testing showed severe inflammation, with a white blood cell count of 16,860/μL and a C-reactive protein level of 20.70 mg/dL. Computed tomography and ERCP showed a retroperitoneal abscess and a pancreatic fistula that had been induced by stent migration. After removing the migrated stent using endoscopy, the pancreatic fistula was treated with a long plastic stent with double flaps to inhibit migration. The retroperitoneal abscess was treated with two drainage tubes placed into the retroperitoneal cavity, via percutaneous transhepatic and endoscopic naso-pancreatic routes. The patient recovered and was discharged 40 days later without further surgical treatment. She has remained free of any symptom during one year of follow-up. Complications of pancreatic stents are rare, but they can induce severe illness.

The need for sedation during gastrointestinal endoscopy has recently been increasing because of the widespread use of time-consuming endoscopic procedures such as endoscopic submucosal dissection. Guidelines for Endoscopy Sedation have been established by the Japan Gastrointestinal Endoscopy Society to describe the ideal methods of sedation during various endoscopic procedures. Recently, propofol and dexmedetomidine have been used for sedation during gastrointestinal endoscopy. It will be important for endoscopists to learn the characteristics of various sedative drugs, methods of use and monitoring methods.

Colitis-associated cancer/dysplasia is an important complication of ulcerative colitis (UC). However, it is difficult to diagnose the range and depth of the lesion of colitis-associated cancer/dysplasia. Even detection of such lesions is often difficult. Neoplastic atypical epithelium (dysplasia) is a precancerous lesion and a target of surveillance colonoscopy. Surveillance colonoscopies are performed starting 7 to 10 years after the onset of UC, preferably in the remission period. There are various macroscopic forms of UC-related tumors. However, dysplasias are often protruded. The presence of different mucosal patterns and color tone changes may suggest the presence of dysplasia. Redness with a demarcation line is also an important sign. In addition to white light observation, image-enhanced endoscopic methods such as chromoendoscopy and magnifying endoscopy are helpful. Histological examination is most important. In the past, step biopsy was recommended, but recently target biopsy was shown to be sufficient. Regarding examination of biopsy specimens, immunostaining for Ki-67 and p53 is also important. Determination of whether a tumor is derived from inflammation or not is important for treatment planning. Patients with colitis-associated cancer require total colectomy. The presence of surrounding dysplasia and overexpression of p53 protein suggests colitis-associated tumor.

In May 2017, the authors visited the Institute for Training & Technology (IT&T) in the United States. The IT&T was designed and developed by the American Society for Gastrointestinal Endoscopy (ASGE), a medical society committed to advancing patient care and digestive health by promoting excellence and innovation in endoscopy. The IT&T offers a flexible, technically-sophisticated environment and a variety of technical training programs. However, it might be difficult to introduce the same system as IT&T in Japan. The Japanese Gastroenterological Endoscopy Society (JGES) still faces many challenges in improving the educational system to develop and maintain the endoscopic knowledge and skills of its members.

Background and Aim : Use of proton pump inhibitors (PPI) is histologically associated with oxyntic gland dilatations. Two interesting mucosal changes are often detected endoscopically in patients who use PPI : gastric cracked mucosa (GCM) and gastric cobblestone-like mucosa (GCSM). The aim of the present study was to clarify the relationship between PPI use and these mucosal changes.

Methods : This was a single-center observational study. All successive subjects who underwent a routine esophagogastroduodenoscopy (EGD) between August and November 2014 in Hokkaido University Hospital were enrolled. Endoscopists carried out the assessment blinded to the use of PPI and checked for GCSM and GCM using original diagnostic criteria for GCM and GCSM. Subjects were divided into two groups : those who used PPI (PPI group) and those who did not (control group). Endoscopic findings and backgrounds were compared between the two groups.

Results : A total of 538 patients were analyzed (control group : 374 patients, men/women : 204/170, median age : 65.2 years ; PPI group : 164 patients, men/women : 89/75, median age : 67.1 years). GCM was detected in 54 (10.0％) subjects, and GCSM was detected in 18 (3.3％) subjects. There was a significant difference in the prevalence rate of GCM between the control group (14/374, 3.7％) and the PPI group (40/164, 24.4％) (P＜0.01). GCSM was significantly more prevalent in the PPI group (15/164, 9.1％) than in the control group (3/374, 0.8％) (P＜0.01).

Conclusion : Novel GCM and GCSM endoscopic findings in the corpus area seem to be strongly associated with PPI use.